Surcharge Remmitance Form - Wireline, Wireless Post-Paid And Voip Page 2
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1
2STATE OF MAINE
WIRELINE, WIRELESS POST1PAID AND VoIP
MONTHLY E9-1-1 SURCHARGE REMITTANCE FORM
PLEASE COMPLETE AND INCLUDE WITH YOUR SURCHARGE REMITTANCE
COMPANY NAME:
_____________________________________________ FEDERAL ID #___________
D/B/A: ____________________________________________________________
ADDRESS: _________________________________________________________
CITY, STATE: ______________________________________ZIP: _______________
CHECK DATE:_____________CHECK NO:_______________SUBMITTED FOR____________MO/YR
REMITTANCE FORMULA
OF SERVICE LINES
LINES X RATE PER LINE
1. NUMBER
:
+
: .37 = _____________
LINES X RATE PER LINE
2. NUMBER OF UNCOLLECTABLES:
-
: .37 = _____________
:
LINES X RATE PER LINE:
3. RECOVERED UNCOLLECTABLES
+
.37 = _____________
OTHER ADJUSTMENTS
LINES X RATE PER LINE:
4.
:
+ or -
.37 = _____________
&
EXPLANATIONS:
5. REMITTANCE TOTAL:
=
$______________
COMMENTS:
PREPARED BY
ATE
:
D
: _______________________
TELEPHONE
(
)
FAX
:
___________________________________
: (
) __________________
MAILING ADDRESS
: __________________________________________
ZIP
__________________________________________
: _________________________
REMIT TO:
TREASURER, STATE OF MAINE E9-1-1
EMERGENCY SERVICES COMMUNICATION BUREAU
MAIL: 18 SHS, AUGUSTA, ME 04333
DELIVERY SERVICE: 101 SECOND ST, HALLOWELL, ME 04347
Updated 12-09. Effective January 1, 2010
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