Cmrs W9-1-1 Fund - Monthly Remittance Report Template
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1STATE OF ARKANSAS
CMRS W9-1-1 FUND
Monthly Remittance Report
Company Name:
________________________________ TIN: _____________________
__________________________________________________________
__________________________________________________________
State of AR Permit No: __________________________________________________________
Collections Period (Month/Year): ___________________________________
___________________________________
No. Customers
Rate
___________________________________
Gross Service Fees Collected
___________________________________
Less Administrative Fee (1% of Gross) _________________________________
Net Service Fees Remitted
=================================
Prepared By: __________________________
Telephone: ___________________
I declare under penalties of perjury that the above return is true, correct and complete to
the best of my knowledge and belief.
Signature: _____________________________
Date: ________________________
Title:
_____________________________
Mail Report and
Payment by Electronic Transfer:
Payment by Check to:
Wire Funds to:
AR CMRS W911 Fund
US Bank ABA 081000210
1400 W. 3, Ste 100
US Bank of Arkansas A/C #4330436942
Little Rock, AR 72201
AR Commercial Mobile Radio Services
501/371-2127
(CMRS) W911 Fund
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