Wireless Minnesota Telephone Fees Remittance Form
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1WIRED TELEPHONE SERVICE PROVIDER COMPANY NAME
DATE
9-1-1 = 40¢ / TAM = 13¢ / TAP = 5¢
TOTAL = 58¢
Minnesota 9-1-1 Program
Company Contact:
TO:
444 Cedar Street, Town Square, Suite 137
Name:
St. Paul, Minnesota 55101-5126
Phone:
Fax: 651 296-2665
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 58¢)
$
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:
5.
x 58¢ =
-
$
0.00
*
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).
9.
Amount of remittance (line 2 plus/minus lines 3, 4, 5, 6, 7 & 8).
$
0.00
I certify that I am a manager or officer of this telecommunications company and that this report is accurate and true and reflects the appropriate
customer access line count including trunk equivalents, adjustments, and fee amount.
Certified by: _________________________________________________________
Date: _________________
(signature of telecommunications company manager or officer)
Company manager's or officer's telephone #________________________________
*
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 40+13+5 (revised December 8, 2003)
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