Form 911 - Emergency Telephone Service Fee Page 2
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1
2Clear Form
MONTANA
911
Emergency Telephone Service Fee
Rev 06 10
-
Name
______________________________________________
1. FEIN
-
9 1 1
-
Address
____________________________________________
2. Acct ID
/
/
Address
____________________________________________
3. Period ending
4. If this is an amended return, check here
City
_______________________________________________
State
____________
Zip
_______________________________
5. If your address has changed, check this box
and print your new address here
_______________________________________________________________________
If you are no longer in business and want your account
/
/
6.
cancelled, enter your final date of operations here
7. Please check the appropriate box(es):
Prepaid service provider, using
Wireless service provider
Internet service provider/VOIP
Decrement method
Other (please specify)
________
or
Wireline service provider
Average revenue method
_______________________
8. a. All access lines for each month of the quarter
Total of all access lines
1st
2nd
3rd
=
b. Exempt access lines for each month of the quarter
Total exempt access lines
1st
2nd
3rd
=
c. Access lines for each month of the quarter – subtract line 8b. from 8a.
Total access lines
1st
2nd
3rd
=
9. Multiply total access lines on 8c. by $1.00
.
10. Previously written off 911 fees collected this quarter
.
11. Uncollectable 911 fees reported in prior periods
.
12. Total 911 fee due – add lines 9 and 10; then subtract line 11
.
13. Amount paid with this return
.
Signature
Title
_______________________________________
Date
_______________________________________
Phone
_____________________________________
*22180101*
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Parent category: Financial