Carrier Remittance Of Wireless E9-1-1 Funds Form - Illinois Commerce Commission

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CARRIER REMITTANCE OF WIRELESS E9-1-1 FUNDS
CARRIER NAME
CARRIER FEIN #
CARRIER ADDRESS
CITY/ST/ZIP
CONTACT NAME
CONTACT PHONE #
REMITTANCE MONTH
/
REMITTANCE AMT $
CHECK NUMBER
CHECK DATE
REMITTANCE MONTHLY BREAKDOWN:
MO/YR Billed
Amount Remitted
/
/
/
/
/
/
/
TOTAL REMITTED
$
-
**
** Must agree with Remittance Amount listed at top of form.
Send Check and remittance to:
Illinois Commerce Commission
Illinois WETSA
527 East Capitol Avenue
Springfield, IL 62701

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