Free Microsoft Word - wats_chg_0109 - Indiana

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VERIFIED NOTICE OF A CHANGE IN A CERTIFICATE OF TERRITORIAL AUTHORITY TO RESELL WIDE AREA TELEPHONE SERVICE AND/OR INTEREXCHANGE INTRASTATE TELECOMMUNICATIONS SERVICES ISSUED BY THE STATE OF INDIANA (As addressed by Cause No. 38149)
State Form 50490 (R2/1-09)

INDIANA UTILITY REGULATORY COMMISSION

Instructions: Complete all blanks and include supporting documentation as attachments to this form. To the Telecommunications Division of the Indiana Utility Regulatory Commission (IURC): ________________________________________________________________________ Company Name(s) hereby notify/notifies the IURC of a change in the Certificate of Territorial Authority (CTA) to resell wide area telephone services and/or interexchange, intrastate telecommunications services issued to ________________________________________________________________________ Company Name(s) in Cause No._______________ dated____________________ and/or CTA No.___________ dated _______________________________. Each Applicant herein represents that, with regard to any continuing CTA authority, that it: A) Has the financial, managerial, and technical ability to provide the services for which it hereby requests a CTA; B) Will comply with Indiana laws and the Commission's regulations and orders of generic application concerning the resale of WATS and/or interexchange, intrastate telecommunications services in Indiana which do not constitute an unlawful barrier to entry into the telecommunications marketplace for such service; C) Will pay the public utility fee required by I.C. 8-1-6; D) Will advise any LEC of the nature of Applicants use of that LEC's facilities and pay such LEC the lawful Commission approved tariffed rates for such services; and, E) Will notify the Commission within thirty (30) days of any changed or additional name under which it will provide services, and any change of address of Applicant's principal business address or change in name of persons authorized to receive notice on behalf of the Applicant.

The change(s) being noticed herein by Applicant(s) relate to: (check all boxes, complete all blanks that apply, and attach any supporting documents.) 1. Mergers, acquisitions, transfers, the issuance of stock, and/or other evidence of indebtedness. Description of transaction: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 2. Name change, use of assumed business name, etc: (Approval from Secretary of State must be attached.) a) Existing name: _________________________________________________________ b) New name: ____________________________________________________________ 3. Cancellation of existing CTA for: ______________________________________________________________________________ ______________________________________________________________________________ Designated Regulatory Contact Information Include company name, contact person, address, phone & fax numbers and e-mail address for each Applicant: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Verification I affirm under the penalties of perjury that the foregoing representations are true. ________________________________________________________________________________ Officer's Name & Title (printed) Signature & Date (month, day, year):__________________________________________________ Telephone Number: ________________________________________________________________ Acknowledged by the IURC: CTA No.:_________________________________________________________________________ Date (month, day, year): ____________________________________________________________