Spreadsheet: 7cdb4046-08b9-4480-a76f-fe3206491a6f
Sheet: Sheet1

FORM B:  Percent-of-Gross-Revenue Franchise Fee Report Form - City of Portland, Oregon | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12
This form for use by companies subject to franchise compensation calculated as a percentage of revenues.
LINE 1a | Name of Company:_______________________________________________________
LINE 1b | Address (city, state, zip):_______________________________________________________
LINE 2 | Reporting Period:  Year:_______
 |  | ____ | Quarterly report: | ___[NAME] | ___Apr-Jun | ___[NAME] | ___Oct-Dec
 |  | ____ | Minimum Annual Fee report
LINE 3 | Total Revenues Derived in Portland for Reporting Period: |  |  |  |  | $________________
LINE 4 | Revenues Derived in Portland Not Subject to Fee: |  |  |  |  | $________________
 | ( list all by source and amount; attach additional pages if needed )
 | 1. Uncollectibles/bad debt |  |  | $________________
 | 2. Customer late fees & interest |  |  | $________________
 | 3. Federal, state, or local law limitations (specify) |  |  | $________________
 | 4. Other (specify) |  |  | $________________
 | Total |  |  |  |  | $________________
LINE 5 | Subtotal of revenues subject to fee ( subtract LINE 4 from LINE 3 ) |  |  |  |  | $________________
Instructions for Line 6a, b, and c:  This is for franchises, temporary revocable permits, and other agreements that specify separate treatment of revenues from system sales, system leases, or Indefeasible Rights of User Interest (IRUs).  If your agreement does not specify separate treatment of those revenues, enter "0."
LINE 6a | Revenue derived from Portland portion of system sales |  |  |  | $________________
LINE 6b | Revenue derived from Portland portion of system leases |  |  |  | $________________
LINE 6c | Revenue derived from Portland portion of IRUs |  |  |  | $________________
LINE 6d | Total of 6a plus 6b plus 6c |  |  |  |  | $________________
LINE 7 | Subtotal of revenues subject to fee ( subtract LINE 6d from LINE 5 ) |  |  |  |  | $________________
LINE 8 | Compensation rate: |  |  |  |  | 0.05
LINE 9 | Subtotal of fee ( multiply LINE 7 by LINE 8 ) |  |  |  |  | $________________
LINE 10 | Enter amount from LINE 9 |  |  |  |  | $________________
LINE 11a | Enter amount from LINE 6a ( sales ) |  |  |  | $________________
LINE 11b | Compensation rate on sales revenue |  |  |  | %: _____________
LINE 11c | Fee on sales revenue ( multiply LINE 11a by LINE 11b ) |  |  |  |  | $________________
LINE 12a | Enter amount from LINE 6b ( leases ) |  |  |  | $________________
LINE 12b | Compensation rate on lease revenue |  |  |  | %: _____________
LINE 12c | Fee on lease revenue ( multiply LINE 12a by LINE 12b ) |  |  |  |  | $________________
LINE 13a | Enter amount from LINE 6c ( IRUs ) |  |  |  | $________________
LINE 13b | Compensation rate on revenue from IRUs |  |  |  | %: _____________
LINE 13c | Fee on IRU revenue ( multiply LINE 13a by LINE 13b ) |  |  |  |  | $________________
LINE 14 | Subtotal of fee ( add LINES 10, 11c, 12c, and 13c ) |  |  |  |  | $________________
LINE 15 | 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 16 | TOTAL FEE ( Subtract LINE 15 from LINE 14 for net credits; add LINE 15 to LINE 14 for net debits )
 |  |  |  |  |  | $________________
LINE 17 | MINIMUM ANNUAL FEE DUE FOR THIS YEAR. |  |  |  |  | $________________
 | ( Enter 0 if previously paid and reported )
LINE 18 | TOTAL REMITTANCE:  ( Greater of LINE 16 or LINE 17 ) |  |  |  |  | $________________
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