Office Of Statewide Emergency Telecommunications Form - State Of Connecticut - 2008
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1State of Connecticut
Office of Statewide Emergency Telecommunications
Surcharge Remittance
2008
Telephone Carrier Information:
Company Name: ________________________________________
Contact Name:__________________________________________
Address: _______________________________________________
________________________________________________
Telephone: _________________ Fax Number: ________________
Email Address: __________________________________________
Period Covered by Check: _________________________________
Month/Year
PAYMENT OPTION A
Number of Telephone Lines
Amount Due
1 Line
@ $0.46:
__________
$____________
2 Lines
@ $0.35:
__________
$____________
3 Lines
@ $0.31:
__________
$____________
4/5 Lines
@ $0.28:
__________
$____________
6-10 Lines
@ $0.23: __________
$____________
11-25 Lines @ $0.18: __________
$____________
26-50 Lines @ $0.15: __________
$____________
51-99 Lines @ $0.12: __________
$____________
100+ Lines @ $0.09:
__________
$____________
TOTAL REMITTED: $____________________
PAYMENT OPTION B (PREPAID ONLY)
Total Revenue Received $_________ ÷ 40 = ____________ X .46 = $ __________
TOTAL REMITTED: $__________________
______________________________________________________________________
Signature
Date
Checks should be made payable to: Office of Statewide Emergency Telecommunications
Mail Surcharge checks and this form to:
Attn: George Pohorilak, OSET Director
Department of Public Safety
1111 Country Club Road
Middletown, CT 06457-929
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