Spreadsheet: 0df5938d-2ee7-4864-afc2-e8c94059a15c
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6
FORM C:  Linear Foot Franchise Fee Report Form - City of Portland, Oregon
This form for use by companies that pay compensation calculated by the linear foot of facilities in the streets.
LINE 1a | Name of Company:_______________________________________________________
LINE 1b | Address (city, state, zip):_______________________________________________________
LINE 2 | Reporting Period:  Year:_______
 |  | ___Annual Report |  | ___Minimum Annual Fee
 |  | ( answer all ) |  | ( skip to LINE 14 )
LINE 3 | Total Linear Footage of Facilities owned in Portland's Public Streets and Rights-of-Way (parallel to street/RoW centerline. Do not count footage perpendicular to centerline).
 | Sources of Linear Foot Figure |  |  | Amount (in feet)
 | 1. Electronic as-built drawings (feet) |  |  | ________________
 | 2. Paper as-built drawings (feet) |  |  | ________________
 | 3. As-designed drawings (feet) |  |  | ________________
 | 4. Other (specify) |  |  | ________________
 | TOTAL |  |  |  | ________________
LINE 4 | Per-foot fee paid last year (e.g., $3.48) |  |  |  | $________________
LINE 5 | CPI change from Dec 31 of prior year to Dec 31 of report year |  |  |  | %_______________
 | ( CPI figure to be provided by the City )
LINE 6 | Applicable per-foot fee for report year |  |  |  | $________________
LINE 7 | Subtotal of linear foot fee ( multiply LINE 3 by LINE 6 ) |  |  |  | $________________
Instructions for LINES 8, 9, and 10:  Only answer if the franchise, temporary revocable permit, or other agreement specifies separate treatment of revenues from system sales, system leases, or Indefeasible Rights of User Interest (IRUs).
LINE 8a | Revenue derived from Portland portion of system sales |  |  |  | $________________
LINE 8b | Compensation rate on sales revenue |  |  |  | %: _____________
LINE 8c | Fee on sales revenue ( multiply LINE 8a by LINE 8b ) |  |  |  |  | $________________
LINE 9a | Revenue derived from Portland portion of system leases |  |  |  | $________________
LINE 9b | Compensation rate on lease revenue |  |  |  | %: _____________
LINE 9c | Fee on lease revenue ( multiply LINE 9a by LINE 9b ) |  |  |  |  | $________________
LINE 10a | Revenue derived from Portland portion of IRUs |  |  |  | $________________
LINE 10b | Compensation rate on revenue from IRUs |  |  |  | %: _____________
LINE 10c | Fee on revenue from IRUs ( multiply LINE 10a by LINE 10b ) |  |  |  |  | $________________
LINE 11 | Subtotal of fee ( add LINES 7, 8c, 9c, and 10c ) |  |  |  |  | $________________
LINE 12 | Other Credits / Adjustments ( list all by source and amount; attach additional pages if needed ):
 | 1. Minimum Annual Fees previously paid for this year. |  |  | $________________
 | 2. Other (specify) |  |  | $________________
 | Total |  |  |  |  | $________________
LINE 13 | TOTAL FEE ( Subtract LINE 12 from LINE 11 for net credits; add LINE 12 to LINE 11 for net debits )
 |  |  |  |  |  | $________________
LINE 14 | MINIMUM ANNUAL FEE DUE FOR THIS YEAR. |  |  |  |  | $________________
 | ( Enter 0 if previously paid and reported )
LINE 15 | TOTAL REMITTANCE:  ( Greater of LINE 13 or LINE 14 ) |  |  |  |  | $________________
Signature: |  |  |  |  | Date
_____________________________________________________________________________
Print name, title, telephone number and email address
I hereby certify that all statements made in this report and any of its attachments are true, complete and accurate to the best of my knowledge.
Remit to: City of Portland, Office for Community Technology, P.O. Box 745, Portland, OR 97207-0745
Form issue date:  12/29/09