TRS Fund Annual State Filing

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Overview

PRA
Instructions
Filing Information
Flat Rate Costs
Per Minute Costs
Add. Costs Paid To Provider

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Sheet 1: PRA

	TRS Fund Annual State Filing	DRAFT - NOT FOR PUBLIC USE Not Approved By OMB TRS Fund State Form Jan 2022 Version OMB Control Number 3060-0463 Estimated Average Burden Hours Per Response: 1.0 Hour
	PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS
	The FCC is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. If we believe there may be a violation or a potential violation of a FCC statute, regulation, rule or order, your certification may be referred to the Federal, state or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order. In certain cases, the information in your certification may be disclosed to the Department of Justice or a court or adjudicative body when a) the FCC; or b) any employee of the FCC; or c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding.
	We have estimated that this collection of information will take 1.0 hour annually. Our estimate includes the time to read the instructions, look through existing records, gather and maintain required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, Office of Managing Director, AMD-PERM, Washington, DC 20554, Paperwork Reduction Act Project (3060-0463). We will also accept your PRA comments if you send an e-mail to [email protected].
	Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number and/or we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-0463.
	THIS NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93- 579, DECEMBER 31, 1974, 5 U.S.C. SECTION 552a(e)(3) AND THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

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Sheet 2: Instructions

	TRS Fund Annual State Filing Instructions								DRAFT - NOT FOR PUBLIC USE Not Approved By OMB TRS Fund State Form Jan 2022 Version OMB Control Number 3060-0463 Estimated Average Burden Hours Per Response: 1.0 Hour
	Below are general instructions for completing this filing workbook. For complete instructions, please reference the Annual Filing - State Instructions document. Any questions should be submitted to Rolka Loube by emailing [email protected].
	Worksheet	Instructions
	Filing Information	Use the provided areas to supply state, filing year, preparer, and attesting officer information.
	Flat Rate Revenue	For TTY, STS, or CTS providers, supply requested data for flat rate service contracts.
	Per Minute Revenue	For TTY, STS, or CTS providers, supply requested data for per minute rate service contracts.
	Add. Revenue Paid To Provider	Supply requested data for revenue received for programs that support TTY, STS, and/or CTS above those associated with provisioning the service (i.e., outreach, billing, administration).

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Sheet 3: Filing Information

TRS Fund Annual State Filing

DRAFT - NOT FOR PUBLIC USE Not Approved By OMB TRS Fund State Form Jan 2022 Version OMB Control Number 3060-0463 Estimated Average Burden Hours Per Response: 1.0 Hour

Preparer Name

Preparer's Email Address

Preparer's Telephone

Filing Period

Signed By:

Senior Officer Name

Senior Officer Title

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.

Persons willfully making false statements on this form can be punished by fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. §1001.

Date

Signature

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Sheet 4: Flat Rate Costs

TRS Fund Annual State Filing Flat Rate Costs

DRAFT - NOT FOR PUBLIC USE Not Approved By OMB TRS Fund State Form Jan 2022 Version OMB Control Number 3060-0463 Estimated Average Burden Hours Per Response: 1.0 Hour

For each contact for which the state received TTY, STS, and/or CTS service at a flat rate, supply the following information.

Provider

Rate Covers Services

Rate Start

Rate End

Reported as Annual Total or Monthly Rate

Flat Rate Amount

Conversation Minutes Serviced During Rate Period

TTY

STS

CTS

TTY

STS

CTS

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Sheet 5: Per Minute Costs

			DRAFT - NOT FOR PUBLIC USE Not Approved By OMB TRS Fund State Form Jan 2022 Version OMB Control Number 3060-0463 Estimated Average Burden Hours Per Response: 1.0 Hour
		For each contract for which the state received TTY, STS, and/or CTS service at a per minute rate, supply the following information.
		Provider	Service	Rate Start	Rate End	Per Session or Conversation Minute	Per Minute Rate	Minutes Serviced During Rate Period
								Conversation	Session

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Sheet 6: Add. Costs Paid To Provider

TRS Fund Annual State Filing Additional Costs Paid To Provider

DRAFT - NOT FOR PUBLIC USE Not Approved By OMB TRS Fund State Form Jan 2022 Version OMB Control Number 3060-0463 Estimated Average Burden Hours Per Response: 1.0 Hour

For each contact for which the state received TTY, STS, and/or CTS service and paid additional funds above those related to provision service minutes, supply the following information.

Provider

Add. Costs Covers

Cost Start

Cost End

Reported as Annual Total or Monthly Cost

Amount

Program

Other Description

TTY

STS

CTS