Form Rpd-41114 - Enhanced 911 Services Surcharge

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WHEN TO FILE:
LINE INSTRUCTIONS
,
,
ENHANCED 911 SERVICES SURCHARGE
1. Qualified Access Lines
,
.
0
0 0
CRS I.D.
2. Uncollectable Lines
,
.
REPORT PERIOD
$
3. E911 Surcharge Collected
-
-
,
.
$
4. Database Surcharge Collected
Beginning (mm-yy)
Ending (mm-yy)
,
.
$
For Department Use Only
5. Total Surcharge
,
.
$
6. Administrative Costs
,
.
$
7. Surcharge Remitted
,
.
$
Please print your numbers like this:
8. Penalty
8 7 6 5
3 2
0
,
.
$
9. Interest
,
.
$
10. Total Due
RPD-41114
INT. 02/99
s RETAIN THIS PORTION FOR YOUR RECORDS s
,
,
ENHANCED 911 SERVICES SURCHARGE
1. Qualified Access Lines
,
.
0
0 0
CRS I.D.
2. Uncollectable Lines
,
.
REPORT PERIOD
$
3. E911 Surcharge Collected
-
-
,
.
$
4. Database Surcharge Collected
Beginning (mm-yy)
Ending (mm-yy)
,
.
$
For Department Use Only
5. Total Surcharge
,
.
$
6. Administrative Costs
,
.
$
7. Surcharge Remitted
,
.
$
8. Penalty
,
.
$
9. Interest
,
.
Signature _________________________________________ Date _________________
$
10. Total Due
RPD-41114
Mail To:
Taxation & Revenue Department
INT. 02/99
P.O. Box 25123, Santa Fe, NM 87504-5123

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