OREGON PUBLIC UTILITY COMMISSION
REIMBURSEMENT FORM
OREGON TELEPHONE ASSISTANCE PROGRAM (OTAP)
PUC Form 750 (Revised 5/6/2014)
Telecommunications Provider’s Name and Business Office Address
Report Month/Year
Provider:
Address:
*Report due on or before the 21
st
calendar day after the end of the billing
period.
City/State:
Zip:
The OTAP Online System will allow one or
more of your company representatives to
securely log in and file this form monthly. Visit
http://apps.rspf.org/Default.aspx. Please
email Frank Lackey at the address below for
more information.
Prepared by:
Provider Email Address:
Provider Contact Phone No.:
COMPANY ID#:
# of Customers
Rate
OTAP Customers
X
Prorate Customers*
X
*For prorated customers, use back of form
Removed Customers
(Credit/Reimbursement to OPUC)
X
( )
Total Reimbursement from PUC
$
PLEASE CHECK HERE IF YOU WOULD PREFER TO RECEIVE ACH PAYMENTS:
PLEASE CHECK HERE IF THIS IS A REVISED REPORT:
For assistance or information, please call Frank Lackey at 503 378-4927.
E-mail address: frank.lackey@state.or.us
Mail report to:
Public Utility Commission
Oregon Telephone Assistance Program
PO Box 2153
Salem OR 97308-2153
For PUC Use Only
Program: RSPF
Description:
OTAP Reimbursement to telephone company
Approved for payment:
Date:
PCA: 32110-32110
Object: 4974
Vendor No.:
$3.50
0.00
$3.50
$3.50
OREGON PUBLIC UTILITY COMMISSION
REIMBURSEMENT FORM
OREGON TELEPHONE ASSISTANCE PROGRAM (OTAP)
PUC Form 750 (Revised 5/6/2014)
# of people eligible
X
# of days per month eligible
Divided by 30
Total
X
30
X
30
X
30
X
30
X
30
X
30
X
30
X
30
X
30
X
30
X
30
TOTAL
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