Company

Date of Submission

Mailing Address

Data Period:

Year

Quarter:

  1^st    2^nd    3^rd    4th

Contact Name

Type of Filing:

  Original

  Correction

Telephone

Program

(a)

Month:

(b)

Month:

(c)

Month:

(d)

Quarter Totals

(e)

Year-to-Date Totals:

1.0 LINK-UP – FEDERAL

1.1 Applications approved

1.2  Interest waived

$

$

$

$

$

2.0 LINK-UP – UTSAP SUPPLEMENTAL INSTALLATION WAIVER

2.1 Applications approved

2.2 Supplemental installation charges waived

$

$

$

$

$

3.0 LIFELINE – FEDERAL

3.1 Number of customers at end of month

3.2 Applications approved during the month

4.0 LIFELINE – UTSAP

SUPPLEMENTAL

MONTHLY ASSISTANCE

4.1 Number of customers at end of month

4.2 Applications approved during the month

4.3 Total Supplemental Monthly Assistance

$

$

$

$

$

QUARTERLY REPORT TO THE ILLINOIS COMMERCE COMMISSION

STATUS OF UTSAP EXPENDITURES

LOCAL EXCHANGE COMPANY:

FOR CLAENDAR QUARTER ENDING:

UTSAP EXPENDITURE REPORT

Current Quarter

Year to Date*

1.

Telecommunications Expenses

a.

Billing and Data Processing

$

$

b.

Customer Notification and Bill Inserts

c.

Certification Administration (LEC) and Contact Time

(Total of Lines 1-6 below)

1.

Salaries & Fringe Benefits

2.

Materials

3

Postage

4.

Transportation Expenses

5.

Preprinted Forms

6.

Other

d.

Certification Administration (IDPA/SSI)

e.

Service Representative Training

f.

Other, please specify

_____________________

TOTALS

$

$

Less UTSAP Reimbursement Received

$

$

BALANCES

$

$

*

Includes Current Quarter

Note:

Each Local Exchange Company must file the original of this Exhibit A with the Chief Clerk of the Illinois Commerce Commission and forward a copy to the UTSAP Administrator and the Staff Liaison within 30 days after the end of each calendar quarter.  Expenses associated with the Federal Lifeline and Link Up Programs should not be reported on this form.

LECs shall maintain supporting documentation in such a manner as to be able to readily identify the above expenses in appropriate subaccounts.

Quarterly "Totals" reported on this page should correspond to the sum of the monthly "Administrative Costs" reported on Exhibit B by LECs with over 35,000 access lines.