Pursuant to Iowa Code 477C, wireless carriers and wire-line local exchange carriers providing telecommunications service in the state are required to pay $0.03 per month for each telecommunications service phone number they provide in Iowa.

Please provide all of the information requested to ensure your company receives credit for its payment. Payment is due by July 31, 2021.

If you have any questions concerning this form, please contact the Accounting staff at 515.725.7300 or iub.billings@iub.iowa.gov.

**PLEASE NOTE** This form is for reporting fourth quarter FY21 lines (April, May, and June 2021) only.  If you are reporting  information for a different quarter, please select the appropriate form from this webpage: https://iub.iowa.gov/regulated-industries/dual-party-relay-service-assessment#forms

Click "next" to proceed to the form.