Enhanced 911 System Surcharge Return Form - State Of Alaska
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1Haines Borough
Enhanced 911 System Surcharge Return
NOTE: Instructions for completing return and remitting payment are
prescribed in
The Alaska Statute 29.35.131.
Name and mailing address of telephone company: ___________________________________
___________________________________
___________________________________
___________________________________
Return for month of: _________________ , 20 ________
1. Amount of gross E911 system surcharges billed for the month:
$ __________ +
$ __________ =
1. $ ___________
(land lines)
(cell)
(all phones)
2. Less E911 amounts charged off as uncollectable as
a. based on actual experience, or;
2a. $ ___________
b. based on estimates in accordance with AMC 26.65.053.B.5
2b. $ ___________
and with;
c. adjustment* of estimates to actual experience:
2c. $ ___________
*No later than December of each year, estimated uncollectables must be adjusted to actual.
3. Plus: Amount of prorated net recoveries collected this month:
3. $ ___________
4. Subtotal:
4. $ ___________
5. Less: Allowable* credit for administrative costs:
Greater of $150.00 or 1% of line 4.
5. $ ___________
*Allowable only if a properly filed return and full remittance are submitted to the
Department on or before 60 days following the end of the month in which the E911
system surcharges are billed.
6. Net amount to be remitted with this return:
6. $ ___________
I certify under oath that this return, including any accompanying information, has been examined by me and to
the best of my knowledge and belief is complete and correct.
Signed: _________________________________Date: _____________ Phone: _________________
Printed Name: _______________________ Title: __________________ E-Mail: _____________________
Return this form, with payment, to:
Haines Borough
Finance Department
E 911 Surcharge
P.O. Box 1209
Haines, Alaska 99827
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