Wireless Service Fee Remittance Report Form - Commission On State Emergency Communications

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COMMISSION ON STATE EMERGENCY COMMUNICATIONS
WIRELESS SERVICE FEE REMITTANCE REPORT
See back of this form for instructions.
Remitting Carrier Name:
Tax Identification Number:
Address:
City, State, Zip :
Check
Electronic Payment
Paid by: (Circle One)
Completed By (Print Name and Phone):
Signature:
Wireless Service Fee Payment Calculation
Month Service Fee Collected
$
Gross Service Fees Collected
$ -
1% Administration Fee Allowed
$
Net Wireless Service Fees Remitted
Treasury Deposit Trace Number:
CSEC Use Only:
Deposit #:
Date Remitted:

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