Monthly Remittance Report
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1STATE OF ARKANSAS
Arkansas Emergency Telephone Services Board
W9-1-1/VoIP 911 FUND
Monthly Remittance Report
Effective 7/31/2009
Company Name: ________________________________ TIN: _____________________
__________________________________________________________
__________________________________________________________
State of AR Permit No:
__________________________________________________________
Collections Period (Month/Year):
___________________________________
___________________________________
No. Customers
Rate
___$.65_____ _______________________
Gross Service Fees Collected
___________________________________
Less Administrative Fee (1% of Gross) _________________________________
Net Service Fees Remitted
=================================
Prepared By:
__________________________
Telephone: ___________________
Email: ________________________________
I declare under penalties of perjury that the above return is true, correct and complete to the best
of my knowledge and belief.
Signature: _____________________________ Date: ________________________
Title:
_____________________________
Email:
_____________________________
Mail Report and
Payment by Electronic Transfer:
Payment by Check to:
Wire Funds to:
Arkansas Emergency Telephone Services Board
US Bank ABA 081000210
1401 W Capital, Suite 245
US Bank of Arkansas A/C #4330436942
Little Rock, AR 72201
Arkansas Emergency Telephone Services
501.375.9911
Fax: 501.372.4304
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