Interstate TRS Fund Annual Provider Information

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Overview

Basics
Rate and Minute Data
Add. Provider-Paid Costs
Add. Costs Paid to Provider
VRS
IP Relay
IP CTS
VRS Demand
IP Relay Demand
IP CTS Demand
Appendix 1

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Sheet 1: Basics

Interstate TRS Fund
Annual Provider Information
Provider Name
Contact Name
Contact Email Address
Contact Telephone
For signature at the bottom of this form:
Senior Officer Name
Senior Officer Title
To assist RolkaLoube in understanding your data, in the box below, please summarize any service changes/activities/improvements since the 2016-2017 filing, or planned for tariff year 2018-2019 (July thru June), that caused/may cause substantial changes in cost and/or demand data. Include the methodology used to determine the projected minutes for calendar years 2018 and 2019. Examples: addition of a state; loss of a state contract; increase in volumes due to specific outreach program; call volume decrease due to use of internet or other non-TRS technology; decrease in minutes due to new, time saving technology; changes in volumes due to abnormal weather conditions; etc. Include any characteristics unique to a particular service or changes in the relay services marketplace as a whole.
Should you have questions about completing or submitting these forms, please see the filing instructions.
I swear under penalty of perjury that I am _______________________, __________________________, an officer of the above-named reporting entity and that I have examined the foregoing reports and that all requested information has been provided and all statements of fact, are true and accurate.
	Signature				Date

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Sheet 2: Rate and Minute Data

Interstate TRS Fund
2017 Intrastate Rate and Minute Data for MARS Methodology
					Actual Intrastate Per Minute Compensation Rates		Number of Intrastate Minutes
Report data for calendar year 2017
Provider	Service Type	Jurisdiction	Rate Start Date	Rate End Date	Conversation Rate	Session Rate	Conversation Minutes	Session Minutes

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Sheet 3: Add. Provider-Paid Costs

Interstate TRS Fund
Additional Provider-Paid Costs for Calendar Year 2017
Provider	Service Type	Jurisdiction	Rate Start Date	Rate End Date	Amount	Description

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Sheet 4: Add. Costs Paid to Provider

Interstate TRS Fund
Additional Costs Paid to Provider for Calendar Year 2017
Provider	Service Type	Jurisdiction	Rate Start Date	Rate End Date	Amount	Description	Source

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Sheet 5: VRS

Interstate TRS Fund
Video Relay Services Expense and Capital Investments Data
Provider:	Actuals		Projection
	2016	2017	2018	2019
A. Annual Recurring Fixed / Semi-Variable Expenses
1. Rent
2. Utilities
3. Building Maintenance
4. Property Tax (if owned)
5. Furniture (if leased)
6. Office Equipment (if leased)
Total	$-	$-	$-	$-
B. Annual Recurring Variable Expenses (Direct TRS Operating Expenses)
1. Salaries & Benefits (Relay Center: Non - Management)
2. Salaries & Benefits (Relay Center: Management)
3. Salaries & Benefits (Relay Center Staff)
4. Telecommunications Expenses
5. Billing Expenses
6. Relay Center Expenses
Total	$-	$-	$-	$-
C. Annual Administrative Expenses
1. Finance/Accounting
2. Legal/Regulatory
3. Engineering
4. Research and Development
5. Operations Support
6. Human Resources
7. Billing
8. Contract Management
9. Risk Management
10. Other Corporate Overheads
Total	$-	$-	$-	$-
D. Annual Depreciation Associated with Capital Investment
1. Furniture & Fixtures
2. Telecommunications Equipment
3. Leasehold
4. Software
5. Other Capitalized
Total	$-	$-	$-	$-
E. Other TRS Expenses
1. Marketing/Advertising Expenses
2. Outreach Expenses
3. Sub Contractor Expenses
4. Software
5. Customer Premise Equipment
6. Other
Total	$-	$-	$-	$-
F. Capital Investments
1. Furniture & Fixtures
2. Telecommunications Equipment
3. Leasehold
4. Software
5. Other Capitalized
Total	$-	$-	$-	$-
G. Costs Associated with E911 and Numbering with Internet-Based Telecommunications Relay Services

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Sheet 6: IP Relay

Interstate TRS Fund
IP Relay Services Expense and Capital Investments Data
Provider:	Actuals		Projection
	2016	2017	2018	2019
A. Annual Recurring Fixed / Semi-Variable Expenses
1. Rent
2. Utilities
3. Building Maintenance
4. Property Tax (if owned)
5. Furniture (if leased)
6. Office Equipment (if leased)
Total	$-	$-	$-	$-
B. Annual Recurring Variable Expenses (Direct TRS Operating Expenses)
1. Salaries & Benefits (Relay Center: Non - Management)
2. Salaries & Benefits (Relay Center: Management)
3. Salaries & Benefits (Relay Center Staff)
4. Telecommunications Expenses
5. Billing Expenses
6. Relay Center Expenses
Total	$-	$-	$-	$-
C. Annual Administrative Expenses
1. Finance/Accounting
2. Legal/Regulatory
3. Engineering
4. Research and Development
5. Operations Support
6. Human Resources
7. Billing
8. Contract Management
9. Risk Management
10. Other Corporate Overheads
Total	$-	$-	$-	$-
D. Annual Depreciation Associated with Capital Investment
1. Furniture & Fixtures
2. Telecommunications Equipment
3. Leasehold
4. Software
5. Other Capitalized
Total	$-	$-	$-	$-
E. Other TRS Expenses
1. Marketing/Advertising Expenses
2. Outreach Expenses
3. Sub Contractor Expenses
4. Software
5. Customer Distributed Equipment
6. Other
Total	$-	$-	$-	$-
F. Capital Investments
1. Furniture & Fixtures
2. Telecommunications Equipment
3. Leasehold
4. Software
5. Other Capitalized
Total	$-	$-	$-	$-
G. Costs Associated with E911 and Numbering with Internet-Based Telecommunications Relay Services

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Sheet 7: IP CTS

Interstate TRS Fund
IP CTS Services Expense and Capital Investments Data
Provider:	Actuals		Projection
	2016	2017	2018	2019
A. Annual Recurring Fixed / Semi-Variable Expenses
1. Rent
2. Utilities
3. Building Maintenance
4. Property Tax (if owned)
5. Furniture (if leased)
6. Office Equipment (if leased)
Total	$-	$-	$-	$-
B. Annual Recurring Variable Expenses (Direct TRS Operating Expenses)
1. Salaries & Benefits (Relay Center: Non - Management)
2. Salaries & Benefits (Relay Center: Management)
3. Salaries & Benefits (Relay Center Staff)
4. Telecommunications Expenses
5. Billing Expenses
6. Relay Center Expenses
Total	$-	$-	$-	$-
C. Annual Administrative Expenses
1. Finance/Accounting
2. Legal/Regulatory
3. Engineering
4. Research and Development
5. Operations Support
6. Human Resources
7. Billing
8. Contract Management
9. Risk Management
10. Other Corporate Overheads
Total	$-	$-	$-	$-
D. Annual Depreciation Associated with Capital Investment
1. Furniture & Fixtures
2. Telecommunications Equipment
3. Leasehold
4. Software
5. Other Capitalized
Total	$-	$-	$-	$-
E. Other TRS Expenses
1. Marketing/Advertising Expenses
2. Outreach Expenses
3. Sub Contractor Expenses
4. Software
5. Customer Distributed Equipment
6. Other
Total	$-	$-	$-	$-
F. Capital Investments
1. Furniture & Fixtures
2. Telecommunications Equipment
3. Leasehold
4. Software
5. Other Capitalized
Total	$-	$-	$-	$-
G. Costs Associated with E911 and Numbering with Internet-Based Telecommunications Relay Services

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Sheet 8: VRS Demand

Interstate TRS Fund
Annual VRS Demand Data
Provider:
	Interstate Video Relay Service (VRS) Conversation Minutes
	Actuals		Projected
	2016	2017	2018	2019
January
February
March
April
May
June
July
August
September
October
November
December

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Sheet 9: IP Relay Demand

Interstate TRS Fund
Annual IP Relay Demand Data
Provider:
	Interstate Internet Protocol Relay (IP-Relay) Conversation Minutes
	Actuals		Projected
	2016	2017	2018	2019
January
February
March
April
May
June
July
August
September
October
November
December

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Sheet 10: IP CTS Demand

Interstate TRS Fund
Annual IP CTS Demand Data
Provider:
	Interstate Internet Protocol Captioned Telephone Service (IP CTS) Conversation Minutes
	Actuals		Projected
	2016	2017	2018	2019
January
February
March
April
May
June
July
August
September
October
November
December

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Sheet 11: Appendix 1

DRAFT _ NOT FOR PUBLIC USE

Not Approved by OMB

2017 Version

OMB Control number XXXX-XXXX

See instructions for public burden estimate

Appendix 1 for IP Relay, IP_CTS, and VRS

See Instructions for Appendix 1