Wireless Enhanced 911 Surcharge Remittance Form

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STATE OF IOWA
WIRELESS ENHANCED 911 SURCHARGE REMITTANCE
TO:
Homeland Security and Emergency Management Division
Attn: E911 Program Manager
th
7105 NW 70
Ave.
Camp Dodge – Bldg. W4
Johnston, IA 50131
PAYABLE TO:
IOWA HOMELAND SECURITY AND EMERGENCY
MANAGEMENT DIVISION
Wireless Service Provider: __________________________________ (Company name)
Contact Person:
__________________________________
Address:
__________________________________
City, State, Zip:
__________________________________
Phone:
_______ – _______ – ________________
Enclosed, please find the surcharge collected for the:
st
nd
rd
th
1
2
3
4
calendar quarter for _____________
(year)
(Choose one)
in the amount of $__________________
Signed by:
______________________________________
Please Print Name: ______________________________________
Title:
_______________________________________
This surcharge is to be remitted to the Iowa Homeland Security and Emergency
Management Division within 20 days of the end of the calendar quarter, must be in our
th
th
th
th
office by January 20
, April 20
, July 20
, October 20
. This form with an original
signature must accompany remittance.
Updated 02/07/2011

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