Tp. 2 No. ____________

Cancels Tp. 2 No. ____________

(Name of Public Utility)

Public Service Commission (Date) ____________

3 Empire State Plaza

Albany, New York 12223-1350

This is to certify that the (name of telephone corporation)¹ assents to and concurs in the publication and filing of (rate schedule described below)² (any joint schedule) and revisions thereto which the (name of telephone corporation) may make and file, in which it is shown as a participating corporation, and hereby makes itself a party thereto and bound thereby insofar as such schedule contains joint rates, charges, rules, or regulations applying to communication by telephone (in any way involving use of its toll lines),³ until this authority is revoked by formal and official notice of revocation filed with the Public Service Commission, State of New York, and with the telephone corporation to which this concurrence is given.

Title and No.: ____________

Date of Issue: ____________

Date Effective: ____________ (Name of Corporation)

By (Signature of Officer)

(Title of Officer)