Wireless E-911 Subscriber Fee Submittal Form

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PUBLIC SERVICE COMMISSION OF WEST VIRGINIA
WIRELESS E-911 SUBSCRIBER FEE SUBMITTAL FORM
MONTH OF_______________, 20____
FEIN:
____________________________
COMPANY NAME:
________________________________________________
DBA (IF APPLICABLE):
________________________________________________
MAILING ADDRESS:
________________________________________________
___________________________________________ _____
________________________________________________
CONTACT PERSON: NAME:_____________________________________________
TITLE:_____________ TEL:(_____)____________ EMAIL:______________________
GROSS SUBSCRIBER FEES BILLED $______________
LESS 3% BILLING FEE
$______________
LESS BAD DEBTS
$______________
NET PAYABLE TO PSC
$______________
I certify that the above figures are true and accurate to the best of my knowledge.
____________
________________________________________ ________
Date
Signature

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