Responsible Party (Rp) Surcharge Report - New Hampshire Bureau Of Emergency Communications
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1State of New Hampshire
Bureau of Emergency Communications
Responsible Party (RP) Surcharge Report
(Effective 4/1/10)
For The Calendar Month Of _________or Fiscal Month: from________to_________
Number of New Hampshire access lines (Gross Units) at the end of this month _________.
___________________________________________________
______________________________________
Company Name/Responsible Party
Communications Service Tax (CST#) EIN#
________________________________________________________________________________________________
Mailing Address
_____________________________________________________________________
_________
_________
City
State
Zip
Description
Original
Amended
Adjustment
Gross surcharges billed for the month @ $0.57 per access line
1.
Deductions, credits, and exemptions:
2
a.
Statutory exemption for > 25 lines per customer billing account
b.
Write offs net of recoveries
c.
Customers refusing to pay the surcharge
d.
Credit from prior period (identify month and year)
e.
Suspended Lines
f.
Other (identify)
Total deductions (lines (a) through (f)
3. Reporting assessments made by the Department of Revenue
Administration under Audit
4.
PAY THIS AMOUNT
The Department of Revenue Administration has the right to audit the taxpayer’s books and record upon request in accordance with
RSA 82-A:11a as required by RSA 106-H:9,III,b3.
Under penalties as provided by law, I declare that I have examined this report and to the best of my knowledge and belief it is true,
correct, and complete. If prepared by other than the responsible party, this declaration is based on all information of which he/she
.
has knowledge
Date
Officer or Owner (Print Name)
Signature of Officer or Owner
Title
_______________________________________________________________________ Mail To:
Date
Signature of Individual or Firm Preparing This Return
State of New Hampshire
Bureau of Emergency Communications
33 Hazen Drive
(______)___________________
Concord, New Hampshire 03305
Preparer’s Telephone Number
Telephone #:603-271-6911
Make checks payable to: New Hampshire Bureau of Emergency Communications
Fax #:
603-271-6609
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