Fees 33+10+5 - Minnesota 9-1-1 Program Form
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1WIRED TELEPHONE SERVICE PROVIDER COMPANY NAME
DATE
9-1-1 = 33¢ / TAM = 10¢ / TAP = 5¢
TOTAL = 48¢
Minnesota 9-1-1 Program
Company Contact:
TO:
Room 510, 658 Cedar Street
Name:
St. Paul, Minnesota 55155
Phone:
Fax: 651 297-5368
Fax:
Email: marykay.frisch@state.mn.us
Email:
Fees are due to the Minnesota 9-1-1 Program by the 25th of the month following the month of collection.
The 9-1-1 emergency telephone service fee, TAM (Telecommunications Access Minnesota), and TAP (Telephone Assistance Program) fees are
remitted for the following period:
(Fees totaling less than $25.00 per month will be submitted annually using a different form.)
Month of
($250.00 or more).
OR
Quarter,
(less than $250.00/month but more than $25.00/month).
1.
Total monthly local access customer lines.
- - includes trunk equivalents for centrex customers - -
(Quarterly reports - customers x number of months.)
2.
Unadjusted fee amount (line 1 x 48¢)
$
0.00
+
-
$
3.
Adjustment for fees pro rated on a daily basis for partial monthly service.
+
4.
Adjustment for seasonal disconnects.
-
$
+
*
Adjustment for bad debts.
Number of customers:
-
$
0.00
5.
x 48¢ =
*
Adjustment for customers who refuse to pay fee(s).
6.
+
Enter Number of customers:
+
TAM
-
$
0.00
9-1-1
TAP
x fee amount =
*
Adjustment for exemptions (e.g. Federal).
7.
-
$
+
8.
Other adjustments (please explain on reverse).
-
$
$
0.00
9.
Amount of remittance (line 2 plus/minus lines 3, 4, 5, 6, 7 & 8).
This report is accurate and true and reflects the appropriate customer lines and fee amount.
Certified by: _________________________________________________________
Date: _________________
(signature of authorized company employee)
*
Attach list of customer name, address, and phone number.
PLEASE MAKE CHECKS PAYABLE TO:
MINNESOTA 9-1-1 PROGRAM
(If you have any questions regarding this collection, please contact Mary Frisch at 651.296.4032)
--- DO NOT WRITE BELOW THIS LINE - STATE OF MINNESOTA OFFICE USE ONLY ----
E9-1-1
$
Check #
9-1-1
$
Amount
E9-1-1 WIRELESS
$
Date rec'd
METRO RADIO BD
$
$
Deposit #
TAM
$
TAP
$
FEES 33+10+5 (effective August 1, 2002)
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