Request For Reimbursement Of Recurring And Nonrecurring Costs For Implementation - Alabama

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ALABAMA WIRELESS 9-1-1 BOARD
P.O. Box 587
Opelika, Alabama 36803-0587
Lee Helms, Chairman
Bill Meadows
Max Armstrong, Sec/Treas
Shelly Eslava
Sen. Ted Little
Rep. Mike Hubbard
Request for Reimbursement of Recurring and Nonrecurring
Costs for Implementation of E9-1-1, Phase I
PROVIDER:____________________________________________________________________
CONTACT:_______________________________________________PHONE:______________
ADDRESS:_____________________________________________________________________
______________________________________________________________________
______________________________________________________________________
In accordance with Ala.Code Sec. 11-98-7 & Reg. 225-1-.03-.05 and the agreement for cost recovery, we request the following
reimbursement for implementation of wireless E9-1-1 service in Alabama from the Alabama Wireless 9-1-1 Board.
Recurring Costs
$
Nonrecurring Costs
Total Reimbursement Requested
$
CERTIFICATION
I certify that this claim is correct and valid and is a proper charge against the Alabama Wireless 9-1-1 Board. Pursuant to the
provisions of Ala. Code Sec 11-98-7, I certify that the amount claimed was incurred for the actual costs of complying with the
wireless E-9-1-1 service requirements established by the FCC Order and any rules and regulations which are or may be adopted
by the FCC pursuant to the FCC Order, including, but not limited to, costs and expenses incurred for designing, upgrading,
purchasing, leasing, programming, installing, testing, or maintaining all necessary data, hardware, and software required in
order to provide the service as well as the incremental costs of operating the service.
_______________________________________________
Date ______________________________
Signature of Carrier
(Month, Day, Year)
_______________________________________________
Title
STATE OF
COUNTY OF
I, the undersigned, a Notary Public in and for said County in said State, hereby certify that __________________________, whose name as
________________________ of ___________________________ is signed to the foregoing conveyance, and who is known to me,
acknowledged
before
me
that,
being
informed
of
the
contents
of
the
conveyance,
he,
in
his
capacity
as
such
_________________________________, executed the same voluntarily for and as the act of said _________________________ of the day
that same bears date.
Given under my hand this ______ day of ________________________________.
__________________________________________________
NOTARY PUBLIC
MY COMMISSION EXPIRES:________________________

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