Emergency 911 Fee Remittance Report - Government Of The District Of Columbia

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EMERGENCY 911 FEE REMITTANCE REPORT
Government of the District of Columbia
*** To obtain an electronic copy of this form, send an E-mail to 911fee@dc.gov ***
Company Name:
Contact Name:
(include d/b/a name)
Tax Service Firm:
Address Line 1:
Phone:
Address Line 2:
Fax:
City, State, ZIP:
E-mail:
Federal Tax ID:
Period Ending:
Operating Co. Number:
FILING INSTRUCTIONS
Who Must File:
All providers of local exchange service or exchange access, including wireline providers, wireless providers, and Voice over
Internet Protocol (VoIP) Service Providers (VSPs) in the District of Columbia, as defined in DC Code §34-1803.
When to Remit:
The 15th of the month following the reporting period, due at least quarterly but may be paid monthly.
Where to File:
1.
E-MAIL
Report to:
911fee@dc.gov
Office of Unified Communications-- E911 Fund Mailbox
2.(a) If remitting by wire or ACH,
FAX
the report to:
FAX No. 202-727-4845 (OCFO, Public Safety & Justice)
2.(b) If remitting by check,
MAIL
report w/check payable to:
District of Columbia Treasurer
OCFO, Public Safety & Justice Cluster
300 Indiana Ave, NW, Suite 4068
Washington, D.C. 20001
Columns
A
B
C
D
E
A+B+C+D+E
Month
Description
Total
1
Wireline
Wireless
VOIP
Centrex
PBX Trunks
No. of Access Lines:
n/a
1
No. of Access Lines:
n/a
2
No. of Access Lines:
n/a
3
Total Number of Access Lines:
n/a
4
0
0
0
0
0
Fee per Line:
$
0.76
$
0.76
$
0.76
$
0.62
($0.62)*8
n/a
5
Total E911 Fee Due (Line 5 x Line 4):
6
$
-
$
-
$
-
$
-
$
-
$
-
Check All Categories That Apply:
NET FEE DUE:
7
$
-
AMOUNT REMITTED:
8
Facilities Based
$
9
Reseller
10
VOIP
12
Prepaid (Wireless)
13
Other
1
1PBX Trunk=8PBX stations [per §34-1803 (A)(2)]
Explanations/Comments
Remittance Information
1. Do you provide local service to federal govt. as defined in DC Code §34-1803?
Payment Date:
______ YES
_______ NO
Payment Method (ACH/Wire/Check):
2. Does this remittance include federal lines? _______YES
_______NO
Check No.:
Certification
I hereby certify, under penalty of law, including criminal penalties for false statements under D.C. Code 22-2514, that this return, to the
best of my knowledge and belief, is true, correct and complete.
Signature of Authorized Representative
Title
Date
Typed Name
Telephone Number
Rev. 6-1-2008

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