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									Docket 11M-595T                                                                                                                CHCSM Report Form page 1
                                                   Colorado Public Utilities Commission
                           Colorado High Cost Support Mechanism (CHCSM) Report Form
Revenue Reporting Period of January 1, 2011 through June 30, 2011                                                 Filing DUE September 1, 2011
   Please Check One:                   Original Filing   or   Revised Filing (Revisions Due by Next Filing Date)
                                        CHCSM Worksheet - Complete numbers 101-116, and 201-233 (see instructions before completing)
   Please Check One:
                               or       Declaration of De Minimis Form - Complete numbers 101-117 (see instructions before completing)
    File electronically with E-Filing in Docket 11M-595T or submit a signed hard copy    Colorado High Cost Support Mechanism Administrator
    to:                                                                                  1560 Broadway, Suite 250
                                                                                         Denver, CO 80202-5143
Block 1: Company Identification Information
101    Legal name of reporting entity
102    IRS employer identification number
103    Name reporting entity is doing business as
104    Principal telecommunications business, select up to 2 (enter numbers starting with "1" to show order of importance, see instructions)
  a.   CLEC/CAP               d.    IXC               g.    Paging & Messaging         j.   Private Service      m.   SMR (dispatch)
                                                                                            Provider
  b.   Cellular/PCS/SMR       e.    Local Reseller    h.    Payphone Service          k.    Satellite            n.   Toll Reseller
       (wireless telephony)                                 Provider                   l.   Shared Tenant        o.   Wireless Data
  c.   Incumbent LEC           f.   OSP                i.   Pre-paid Card                   Service Provider     p.   ISP Provider
  q.   Other Local             r.   Other Toll        s.    Other Mobile              If Other, describe:
105    Holding Company (all affiliated companies should show same name)
106    Holding Company IRS employer identification number
107    Management Company (if company is managed by another entity)
108    Complete mailing address of reporting entity's corporate                 Address
       headquarters                                                                 City
                                                                                  State
                                                                                     Zip
Block 2: Contact Information
109    Name of person completing this CHCSM Report Form
110    Contact person for questions on the filing of this                      Name
       CHCSM Report Form                                                      E-mail
                                                                   Telephone Number
111    Contact person for CHCSM - Future CHCSM Report                          Name
       Forms, Invoicing, and PUC Decisions will be sent to the                E-mail
       CHCSM contact
                                                                             Address
                                                                                 City
                                                                               State                                      Zip Code
                                                                   Telephone Number
Block 3: Sale or Acquisition
112       Was this reporting entity sold in the reporting period?                                Yes                        No
          If Yes, provide the date of sale and name of acquiring company
113       Has this reporting entity acquired any companies in the reporting period?              Yes                        No
          If Yes, list the company(ies) acquired and the date of acquisition
Block 4: CHCSM Worksheet Certification or Declaration of De Minimis Certification: (to be signed by an officer of the company.)
I certify that I am an officer of the above-named reporting entity and that I have examined this report and to the best of my knowledge, information,
and belief, all statements of fact contained in this CHCSM Worksheet or De Minimis Form are true and that said CHCSM Worksheet or De Minimis
Form is an accurate statement of the affairs of the above-named reporting entity. I understand that willfully false statements are punishable by fine
under Article 7, Title 40 of the Colorado Revised Statutes.
114       Signature of officer                                                                        Date


115    Printed name of officer
116    Position with company
       Declaration of De Minimis - Colorado High Cost Support Mechanism                                        (see report form instructions)
117     (a) CHCSM Included Intrastate Rev. (see line 232C)      (b) Estimation Factor (c) (CHCSM Included Intrastate Rev.) x (Estimation Factor)
                          $                                             0.029                               $                                      -
Docket 11M-595T                                                                                                             CHCSM Report Form page 2
                                                     Colorado Public Utilities Commission
                                             Colorado High Cost Support Mechanism
Revenue Reporting Period of January 1, 2011 through June 30, 2011                                                   Filing DUE September 1, 2011
Block 5: Contributor Revenue Information
201       Legal Name of Contributor
202       [Reserved -- Do not complete]
I. WHOLESALE REVENUE from Other Carriers and Other Non-End-User Revenues                                     (report Revenues in whole dollars)
Fixed Local Service                                                                                     Colorado Total    Percent        Intrastate
203    Monthly service, local calling, connection charges, vertical features, and other                  Revenues        Intrastate      Revenues
          local exchange service                                                                             (A)             (B)            (C)
      a   Provided as unbundled network elements or other contract arrangement (UNEs)                                          100%                   -
      b   Provided under tariffs or arrangements other than unbundled network elements                                         100%                   -
204       Per minute charges for originating or terminating calls
      a   Provided under state or federal access tariffs                                                                       100%                   -
      b   Provided as unbundled network elements or other contract arrangement                                                 100%                   -
205       Local Private Line and Special Access Services                                                                       100%                   -
206       Payphone compensation from toll carriers                                                                             100%                   -
207       Other local telecommunications service revenues                                                                      100%                   -
208       Universal service support revenues from State and Federal sources                                                    100%                   -
Mobile Service (includes wireless telephony, paging & messaging, and other mobile services)
209    Monthly, activation, and message charges except toll                                                                    100%                   -
Toll Service
210       Operator and toll calls with alternative billing arrangements (credit cards, collect, etc.)                          100%                   -
211       Other switched toll service (includes MTS, toll free 800/888 service, etc.)                                          100%                   -
212       Ordinary Long distance- (Direct-dialed MTS, customer toll-free 800/888 service, "10-10"
          calls, Associated monthly account maintenance, PICC pass through, and other switched
          services not reported above)                                                                                         100%                   -
213    Satellite services                                                                                                      100%                   -
214    All other long distance services                                                                                        100%                   -
 II. RETAIL REVENUE From All Other Sources (End-User Telecom and Non-Telecom)
215    Surcharges or other amounts on end-user bills identified as recovering state or federal
       universal service contributions                                                                                         100%                   -
Fixed Local Service
216    Monthly service, local calling, connection charges, vertical features, and other local
       exchange service charges except for federally tariffed subscriber line charges
    a Provide as a flat rate including intrastate toll service                                                                 100%                   -
    b Provided without intrastate toll included                                                                                100%                   -
217       Tariffed subscriber line charges to end users                                                                        100%                   -
218       Local Private line and special access service                                                                        100%                   -
219       Pay telephone coin revenues                                                                                          100%                   -
220    Other local telecommunications service revenues                                                                         100%                   -
Mobile service (includes wireless telephony, paging & messaging, and other mobile services)
221       Monthly charges and activation charges                                                                               100%                   -
222    Message charges including roaming but excluding toll charges                                                            100%                   -
223    Pre-paid mobile service calling charges reported at face-value of cards                                                 100%
Toll Service                                                                                                                                          -
224       Pre-paid toll calling charges reported at face-value of cards                                                        100%
225       Operator and toll calls with alternative billings arrangements (credit card, collect, etc.)                          100%                   -
226       Other switched toll service (includes MTS, toll free 800/888 service, etc.)                                          100%                   -
227       Long distance private line services                                                                                  100%                   -
228    Satellite services                                                                                                      100%                   -
229    All other long distance services                                                                                        100%                   -
Other Revenues
230    Enhanced services, inside wire maintenance, billing and collection, customer premises
       equipment, and non-telecommunications products and service revenues                                                     100%                   -
231    Miscellaneous Revenues (including Directory Revenue)                                                                    100%                   -
232       Contribution Base; Subtotal of Lines 216 through 229 and Line 231                                        -                                  -
233       Gross billed revenues from all sources (including reseller and non-telecom)                              -                                  -

 PERSONS MAKING WILLFUL FALSE STATEMENTS ON THE WORKSHEET CAN BE PUNISHED UNDER ARTICLE 7, TITLE 40 OF THE COLORADO REVISED STATUTES

								
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