Montana Form Et911 - Emergency Telephone (911) Service Fee Return

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MONTANA
ET911
Rev. 4-04
Emergency Telephone (911) Service Fee Return
10-4-101, MCA
Quarter ending _________/__________/_________
Federal ID #_______________________________
Name and address of the provider of telephone exchange access service
Column a.
Column b.
Column c.
Total
Exempt
Taxable
Access Lines
Access Lines
Access Lines
Total number of lines for each month
First month of quarter
________________ _________________ __________________
..........................
Second month of quarter
________________ _________________ __________________
......................
Third month of quarter
........................
________________ _________________ __________________
1.
Total number of access lines
________________ _________________ __________________
...............
_________________
2.
Fee computation (line 1 of Column c., times $0.50)
................................................
$
Less credit adjustments
Uncollectible accounts
........................
__________________
$
Refunds
............................................
__________________
$
Incorrect billings
__________________
.................................
$
Other credit adjustments
__________________
....................
$
3.
...........................................................................................................
Total credits
$(________________)
Add debit adjustments
..........................
Bad debt adjustments
$__________________
.......................
Other debit adjustments
$__________________
4.
Total debits
............................................................................................................
$_________________
.................................................................................................
Total fees remitted
$_________________
Revenue Account Code
520212
____________ _______________________________________________________
_____________
Date
Signature of Preparer
Print Name
Phone
Retain a duplicate for audit purposes. Returns and remittance for total fees due must be received on or
before the last day of the month following the last day of the calendar quarter. If you have any questions,
please contact our Customer Service Center at:
Montana Department of Revenue
P.O. Box 5835
Helena, MT 59604-5835
(406) 444-6900
This form is also available at
339

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