Form FCC Form 1220 FCC Form 1220 Cost of Service Filing for Reguated Cable Services

Community Unit Operating Name						Community Unit ID (CUID)		Date of Filing
Name of Cable Operator
Mailing Address
City						State		Zip Code
Ownership of Franchise (Place an "X" to the left of the appropriate answer.):
		C-Corp				Subchapter S
		Partnership				Sole Proprietor			Other
Person to contact regarding this form:
Telephone						Fax Number
( )						( )
Local Franchising Authority
Mailing Address
City						State		Zip Code
This form is being filed with respect to (Place an "X" to the left of the appropriate answer.):
		Basic Rate Regulation			OR		Cable Programming Service Rate Regulation
If this form is being filed in response to a complaint about you cable programming service rates, please attach a copy of the complaint
to this cover sheet. Refer to instructions for completing Costs of Service Filing for Regulated Cable Services.
Part I. Revenue Requirement Computation
					(a)	(b)		(c)
Line Number and Description						Basic	CPS	Basic	CPS
1	Net Rate Base					$0	$0
2	Return on Investment
	a. Rate of Return Percentage
	b. Computed Return on Rate Base							$0	$0
3	Allowance for Income Taxes
	a. Federal Income Tax Rate
	b. State Income Tax Rate
	c. Return on Rate Base					$0	$0
	d. Interest Charges					$0	$0
	e. Distributions (Non-C corp. filers only)
	f. Contributions (Non-C corp. filers only)
	g. Return Amount Subject to Income Tax					$0	$0
	h. Income Tax Allowance							$0	$0
4	Total Operating Expenses							$0	$0
5	Total Revenue and Income Adjustments							$0	$0
6	Total Revenue Requirement							$0	$0
Part II. Charges for Regulated Services Computation
					BASIC	CPS
Line Number and Description					Tier 1	Tier 2	Tier 3	Tier 4	Tier 5
1	Revenue Requirements*				$0
2	Number of Subscribers
3	Annual Revenue Requirement per Subscriber				$0.0000	$0.0000	$0.0000	$0.0000	$0.0000
4	Monthly Charge (Ex. Fee)				$0.0000	$0.0000	$0.0000	$0.0000	$0.0000
5	Franchise Fee at:		0.00%	.
6	Service Charge Plus Franchise Fee				$0.00	$0.00	$0.00	$0.00	$0.00
In addition to computed rates based on costs,
provide the following:
7	Current Charges
8	Benchmark Rates
9	Total Revenues
10	Number of Channels
*Provide description of allocation of CPS Revenue Requirement to CPS Tiers:
Part III. External Costs Identification
					BASIC	CPS
Line Number and Description					Tier 1	Tier 2	Tier 3	Tier 4	Tier 5
1	Programming Costs
2	Retransmission Consent Fees
3	Franchise Fees
4	Taxes - Specific to Cable Services
5	Costs of Other Franchise Obligations
CERTIFICATION STATEMENT
	WILLFUL FALSE STATEMENTS MADE ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT
	(U.S. CODE TITLE 18, SECTION 1001), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503).
	I certify that the statements made in this form are true and correct to the best of my knowledge and belief, and are made in good faith.
	Name of the Cable Operator					Signature
	(Entry needed on Page 1 of this form.)
	Date					Title
FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT
We have estimated that each response to this collection of information will take 80 hours. Our estimate included the time to read the
instructions, look through existing records, gather and maintain the required data, and actually complete and review the form or
reponse. If you have any comments on this burden estimate, or on how we can improve the collection and reduce the burden that it
causes you, please e-mail them to [email protected] or send them to the Federal Communications Commission, AMD-PERM, Paperwork
Reduction Project (3060-0594), Washington, DC 20554. Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. Remember -
you are not required to respond to a collection of information sponsored by the Federal government, and the government may not
conduct or sponser this collection, unless it displays a currently valid OMB control number of if we fail to provide you with this notice
This collection has been assigned an OMB control number of 3060-0594.
THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13, OCTOBER 1,
1995, 44 U.S.C. Section 3507.