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Revised 07-2025 City of Woodburn Quarterly Reporting Form Usage fees are due quarterly, in arrears, 30 days after the end of the calendar quarter (April 30, July 30, September 30, and January 30). Name of utility provider: TAX ID: Address: Phone: For the period ending: A. Gross Revenue for the month x (*see below) = Gross Revenue for the month x (*see below) = Gross Revenue for the month x (*see below) = B. Linear footage: feet x (see below) = C. Number of attachments: x (see below) = Total amount due the City of Woodburn *The rights-of-way fee established per Ordinance No. 2583 are as follows and will be remitted quarterly, to the extent permitted under applicable law: Utility Service RoW Usage Fee Rate Electric 5% of gross revenue Natural Gas 5% of gross revenue Communications, excluding Small Cell Wireless Facilities 7% of gross revenue Usage of the Rights-of-Way for purposes other than providing services to residents of the City. $3.00 per linear foot of facilities in the Rights of Way or a minimum fee of $5,000.00 per year, whichever is greater. Attachment fee, excluding Small Cell Wireless Facilities $5,000.00 per attachment, per year ($1,250.00 per calendar quarter). Attachment fee for Small Cell Wireless Facilities $270.00 per attachment, per year ($67.50 per calendar quarter). I, (Print Name), hereby certify, on behalf of licensee, that to the best of my knowledge and belief this statement is correct. Signature Title Date Please remit this form and any funds due to: City of Woodburn Attn: ROW Program, 270 Montgomery St., Woodburn, Oregon, 97071. For questions please contact the City's Finance Department at [PHONE REDACTED] or [EMAIL REDACTED].