Form In-1678 - Non-Wireline Provider Remittance - Standard - Tennessee Emergency Communications Board - Department Of Commerce & Insurance
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1STATE OF TENNESSEE
TENNESSEE EMERGENCY COMMUNICATIONS BOARD
DEPARTMENT OF COMMERCE & INSURANCE
500 JAMES ROBERTSON PARKWAY
NASHVILLE, TENNESSEE 37243-0582
Telephone: 615-253-2164
Fax: 615-401-7642
RANDY PORTER
LYNN QUESTELL
CHAIRMAN
EXECUTIVE DIRECTOR
1
Non-Wireline Provider Remittance - STANDARD
Confidential Information
From (Company):
Address:
Contact Name:
Title:
Telephone Number:
Fax Number:
Pursuant to Tenn. Code Ann. § 7-86-108(a)(1)(B), all non-wireline service providers are required to collect an emergency telephone
2
service charge from each subscriber and user whose place of primary use, as defined by Tenn. Code Ann. § 67-6-102, is in Tennessee.
This form and the remittance shall be submitted to the Tennessee Emergency Communications Board (ECB) no later than thirty (30) days
after the last business day of each two-month collection period. Pursuant to Tenn. Code Ann. § 7-86-317 and Tenn. Comp. R. & Reg.
0780-6-1, the information provided to the ECB on this form is deemed proprietary and will not be released as a public record.
The following is a report for the period from:
_________________
through
_________________
(Date)
(Date)
MONTH 1
MONTH 2
Number of
Number of
3
3
Subscribers and Users
Subscribers and Users
CMRS (cell phones)
____________________
____________________
VoIP
____________________
____________________
Other _______________________________
____________________
____________________
____________________
____________________
Total Subscribers and Users
____________________
____________________
Gross Collection of Telephone Service Charges
____________________
____________________
Amount Collected of Any Past/Overdue Balances
____________________
____________________
Gross Collection plus any other amount collected
=
Net Collection
____________________
____________________
4
Administrative Fee for Collection
____________________
____________________
____________________
____________________
Net Collection less administrative fee
=
Total for Remittance
____________________
____________________
If the Gross Collection amount is different than the number of users and subscribers times $1.00, please explain: ______________
________________________________________________________________________________________________________
Total remittance: ________________________ Effective date of remittance transfer: _____________________
I certify that I am authorized to provide this remittance information on behalf of the company listed above and that, to the best of my
knowledge and belief, the foregoing remittance is accurate, complete, and is the correct amount due.
Signature:
Date:
Name (Print):
Title:
1
Please use this form to account for all users and subscribers who are billed retrospectively, known as standard customers. For prepaid users and
subscribers, please use the form entitled “Non-Wireline Provider Remittance – PREPAID.”
2
“‘Place of primary use’ means the street address representative of where the customer's use of the [non-wireline] service primarily occurs, which
must be the residential street address or the primary business street address of the customer. In the case of mobile telecommunications service,
‘place of primary use’ must be within the licensed service area of the home service provider.” 2007 Tenn. Pub. Acts 602.
3
The 911 service charge applies to all users and subscribers of non-wireline service. If a customer gets one individual service from the carrier (for
example, one cell phone service), only one charge applies; the customer is not counted twice as both a user and a subscriber. If a customer gets
multiple services from the carrier (for example, a family account that includes four different cell phones, or an individual account that includes both a
VoIP phone and a cell phone), the charge applies to each service and user (four charges in the first example, two in the second).
4
Pursuant to Tenn. Code Ann. § 7-86-108(a)(1)(B)(ii)(a), each non-wireline provider is entitled to retain as an administrative fee an amount up to
three percent (3%) of its collections of the service charge.
IN-1678
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