Telephone And Wireless Monthly E9-1-1 Surcharge Remittance Form printable pdf download

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

STATE OF MAINE

TELEPHONE AND WIRELESS

MONTHLY E9-1-1 SURCHARGE REMITTANCE FORM

PLEASE COMPLETE THE FOLLOWING 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

: .50 = $______________

OF UNCOLLECTIBLES

LINES X RATE PER LINE

2. #

: .50 = $______________

OTHER ADJUSTMENTS:

LINES X RATE PER LINE:

+ or -

.50 = $______________

EXPLANATION:

4. REMITTANCE:

$______________

COMMENTS:

PREPARED BY

DATE

: _________________________________________

: ________________________

TELEPHONE

(

)

FAX

___________________________________

: (

) __________________

MAILING ADDRESS

: __________________________________________

ZIP

__________________________________________

: _________________________

REMIT TO:

TREASURER, STATE OF MAINE E9-1-1

EMERGENCY SERVICES COMMUNICATION BUREAU

15 OAK GROVE ROAD, ROOM B-132

VASSALBORO, ME 04989-3201

Updated 4-03

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

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