Wireless E-911 Services Board Wireless E-911 Surcharge Remittance Form - Commonwealth Of Virginia

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COMMONWEALTH of VIRGINIA
Wireless E-911 Services Board
Wireless E-911 Surcharge Remittance Form
Reporting Period:
to
Federal Tax Identification Number:
Company Name:
DBA:
Address:
Contact Name/Phone:
Contact Fax/Email:
Gross Post-paid Subscriber Count
Exempt Post-paid Subscribers
Net Post-paid Subscribers
Gross Post-paid Surcharge Collected
Pre-paid subscribers
Pre-paid remittance method
(monthly/point of sale)
Gross Pre-paid Surcharge Collected
Total Surcharge Collected
Less 3% Administrative Fee
Total Surcharge Amount Remitted
I declared that the above information is true, correct and complete to the best of my
knowledge and belief.
Signature, Title and Date

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