Non-Wireline Provider Remittance Form - 2006
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1Tennessee Emergency Communications Board
NON-WIRELINE Provider Remittance Form
CONFIDENTIAL INFORMATION
Pursuant to Tenn. Code Ann. § 7-86-108(a)(1)(B), all non-wireline service providers are required to collect a wireless enhanced 911
charge from each subscriber and user with a billing address in Tennessee. This form shall be submitted to the Tennessee Emergency
Communications Board (ECB) no later than thirty (30) days after the last business day of each two-month collection period. Pursuant to
Tenn. Code Ann. § 7-86-317 and Tenn. Comp. R. & Reg. 0780-6-1, the information provided to the ECB on this form is deemed
proprietary and will not be released as a public record.
Submit or Fax to: Tennessee Emergency Communications Board
Ninth Floor, Davy Crockett Tower
500 James Robertson Parkway
Nashville, TN 37243
Phone: (615) 253-2164
Fax: (615) 401-7642
From (Company):
Address:
Contact Name:
Contact Title:
Telephone Number:
Fax Number:
The following is a report for the period from
through
(Date)
(Date)
MONTH 1
MONTH 2
Number of
Number of
Subscribers or Users:
Subscribers or Users:
CMRS (cell phones)
VoIP
Other: (identify below)
Total Subscribers or Users:
Fee per Subscriber or User:
$1.00
$1.00
Fee times number of subscribers/users =
Gross Collection Amount:
Administrative fee for Collection:
See Footnote #1
Gross Amount less Administrative fee =
Net Amount:
Amount of Any Uncollectible Charges:
Total Remittance:
Net Amount less Uncollectible Charges =
Total:
I certify that I am authorized to provide the above information and that, to the best of my knowledge
and belief, the foregoing remittance is accurate, complete, and is the correct amount due.
Name:
Title:
Signature:
Date:
Effective date of Remittance transfer:
Footnote #1 Pursuant to Tenn. Code Ann. § 7-86-108(a)(1)(B)(ii), each non-wireline provider is entitled to retain as an
administrative fee an amount equal to three percent (3%) of its collections of the service charge
.
Revised 10/17/2006
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