Enhanced 9-1-1 Uniform Emergency Telephone System Report Of 9-1-1 Surcharge Revenue Form - State Of Rhode Island And Providence Plantations


State of Rhode Island and Providence Plantations
Enhanced 9-1-1 Uniform Emergency Telephone System
Report of 9-1-1 Surcharge Revenue
For the Period beginning
and ending:
Surcharge revenue remitted:
Number of access lines or wireless subscribers:
At $1.00:
less uncollectibles:
Total of Revenue Remitted:
Make check payable to:
State of Rhode Island, General Treasurer
Send report and payment to:
E 9-1-1 Uniform Emergency Telephone System
State of Rhode Island
1951 Smith Street
North Providence, RI 02911
Note: If your company is a reseller and the underlying carrier remits this fee on your company's behalf, please
check this box !
, in
dicate name of underlying carrier here
and complete all of the information below.
Company name:*
Company Identifier Number:
Company address:
Contact person completing report:
Phone number of contact person:
Fax Number of contact person:
E-mail address of contact person:
Signature of person authenticating this report:
Telephone Number:
*As shown on Public Utilities Commission Registration or Federal Communications Commission license/


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