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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:

Subtotal:

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.

REMITTANCE FOR:

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:

Title:

Telephone Number:

*As shown on Public Utilities Commission Registration or Federal Communications Commission license/

certificate.

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