Cmrs Provider Remittance Form - Indiana Wireless Enhanced 911 Advisory Board
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1CMRS PROVIDER REMITTANCE FORM
Submit to:
Indiana Wireless Enhanced 911 Advisory Board
Treasurer of State
State House
200 West Washington Street, Room 242
Indianapolis, Indiana 46204-2792
From:
Wireless Service Provider__________________________
Address________________________________________
City, State Zip___________________________________
Contact name and phone number:__________________________________________
CMRS providers, as defined by IC 36-8-16.5-6, are required to collect a fee from each
subscriber with a billing address in Indiana. Pursuant to IC 36-8-16.5, the following
information pertaining to the number of subscribers is considered proprietary information
and will not be released as a public record.
The following is a reporting of collections for the period from________ through_______.
(date)
(date)
Subscribers:
____________
Reseller Subs:
____________
Prepaid Subs:
____________
Total Subscribers:
____________
Fee:
x . 50
Total Collections:
____________
Less 1.4%:*
- ____________
Total Remittance:
____________
* IC 36-8-16.5-35 A CMRS provider may keep seven tenths of a cent ($.007) of the emergency
wireless enhanced 911 fee collected each month from each subscriber for the purpose of
defraying the administrative costs of collecting the fee.
I certify to the best of my knowledge and belief that the foregoing remittance is accurate
and is the correct amount due the board.
Name(printed):_____________________
Title:____________________________
__________________________________ Date:_____________________________
Signature
January 2006
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