Wireline And Wireless Telephone Monthly E9-1-1 Surcharge Remittance Form

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STATE OF MAINE
WIRELINE AND WIRELESS TELEPHONE
MONTHLY E9-1-1 SURCHARGE REMITTANCE FORM
PLEASE COMPLETE AND INCLUDE WITH YOUR SURCHARGE REMITTANCE
COMPANY NAME:
_______________________________________________
D/B/A:
_______________________________________________
ADDRESS:
_______________________________________________
______________________________________ZIP: _______________
CHECK DATE:_____________CHECK NO:_______________SUBMITTED FOR____________MO/YR
REMITTANCE FORMULA
OF SERVICE LINES
LINES X RATE PER LINE
1. NUMBER
:
+
: .37 = _____________
OF PRE-PAID CARDS
LINES X RATE PER LINE
2. NUMBER
:
+
: .37 = _____________
LINES X RATE PER LINE
3. NUMBER OF UNCOLLECTABLES:
-
: .37 = _____________
:
LINES X RATE PER LINE:
4. RECOVERED UNCOLLECTABLES
+
.37 = _____________
OTHER ADJUSTMENTS
LINES X RATE PER LINE:
5.
:
+ or -
.37 = _____________
&
EXPLANATIONS:
6. REMITTANCE:
=
$______________
COMMENTS:
PREPARED BY
ATE
:
D
: _______________________
TELEPHONE
(
)
FAX
:
___________________________________
: (
) __________________
MAILING ADDRESS
: __________________________________________
ZIP
__________________________________________
: _________________________
REMIT TO:
TREASURER, STATE OF MAINE E9-1-1
EMERGENCY SERVICES COMMUNICATION BUREAU
18 SHS
242 STATE STREET
AUGUSTA, ME 04333
Updated 6-09

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