Responsible'S Parties (Rp) Amended Surcharge Report Form - Bureau Of Emergency Communications Of State Of New Hampshire

ADVERTISEMENT

State of New Hampshire
For Office Use Only
6/28/06-surcharc
Bureau of Emergency Communications
Responsible’s Parties (RP)Amended Surcharge Report
For The Calender Month Of _________or Fiscal Month: from________to_________
Number of NH Hampshire customers at the end of this month _________.
___________________________________________________________________________
________________
Name of Responsible Party
EIN
________________________________________________________________________________________________
Mailing Address
_____________________________________________________________________
_________
_________
City
State
Zip
$$$$$$$$$$$$$$$$$Dollars$$$$$$$$$$$$.
Original
Amended
Adjustment
Description
Gross surcharges billed for the month
1.
Deductions,credits, and exemptions:
2
Statutory exemption for > 25 lines per customer billing account
a.
b.
Write offs net of recoveries
c.
Customers refusing to pay the surcharge
d.
Credit from prior period (identify month and year)
e.
Suspended Lines
f.
Other (identify)
2g. Total deductions (lines (a) through (f))
3 NET AMOUNT OF SURCHARGE DUE (line (1) less line
3
(2 )
4 Interest and Penalties
a. Interest (see instructions)
b Failure to pay (see instructions)
c
Failure to File (see instructions)
d Total of (lines 4 (a) through (c)
5
PAY THIS AMOUNT (line (3) plus line (4d.)
Under penalties as provided by law, I declare that I have examined this report and to the best of my knowledge and belief it is true,
correct, and complete. If prepared by other than the responsible party, this declaration is based on all information of which he/she
.
has knowledge
_____________________
____________________________________
_____________________
Date
Signature of Officer or Owner
Title
Date
Signature of Individual or FirmPreparingThis Return
EIN
(______)___________________
Preparer’s Telephone Number
Mail To:
Make checks payable to: Director-NHBEC (E-9-1-1)
emer_surcharg_amend
State of New Hampshire
Bureau of Emergency Comunications
33 Hazen Drive, Room 105
Concord , New Hampshire 03305

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go