Annual Cost Recovery Statement - Fye 9-30-04 - Alabama Wireless 9-1-1 Board printable pdf download

WIRELESS CARRIER MONTHLY INVOICE

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ALABAMA WIRELESS 9-1-1 BOARD

ANNUAL COST RECOVERY STATEMENT – FYE 9-30-04

PROVIDER:_____________________________________________________________________

CONTACT:_________________________________________PHONE:_____________________

ADDRESS:_______________________________________________________________________

________________________________________________________________________

In accordance with Ala.Code Sec. 11-98-7 & Reg. 225-1-.03-.05 and the Agreement for Cost Recovery for Enhanced

Wireless 9-1-1 Service in Alabama, we report the following (1) total costs for Phase I implementation through 9-30-04, (2)

total reimbursement requested for the period ending 9-30-04, and (3) balance due from or (to) the Alabama Wireless 9-1-1

Board.

(1) Total costs for Phase 1 implementation paid by carrier through 9-30-04

(2)

Less: Total reimbursement requested through 9-30-04

(3)

Balance due from or (due to) Alabama Wireless 9-1-1 Board

CERTIFICATION

I certify that this statement is correct and valid and is a proper charge against the Alabama Wireless 9-1-1 Board. Pursuant to

the provisions of Ala. Code Sec 11-98-7, I certify that the amount claimed was incurred for the actual costs of complying

with the wireless E9-1-1 service requirements established by the FCC Order and any rules and regulations which are or may

be adopted by the FCC pursuant to the FCC Order, including, but not limited to, costs and expenses incurred for designing,

upgrading, purchasing, leasing, programming, installing, testing, or maintaining all necessary data, hardware, and software

required in order to provide the service as well as the incremental costs of operating the service.

_______________________________________________

Date ______________________________

Signature of Carrier

(Month, Day, Year)

_______________________________________________

Title

STATE OF

_______________________________________

COUNTY OF _______________________________________

I, the undersigned, a Notary Public in and for said County in said State, hereby certify that __________________________, whose name as

________________________ of ___________________________ is signed to the foregoing conveyance, and who is known to me,

acknowledged before me that, being informed of the contents of the conveyance, he, in his capacity as such

_________________________________, executed the same voluntarily for and as the act of said _________________________ of the day

that same bears date.

Given under my hand this ______ day of ________________________________.

__________________________________________________

NOTARY PUBLIC

MY COMMISSION EXPIRES:________________________

file://Y:\Pdfwork\Manual\AL\confirm04%20Form%20-%20Annual%20Cost%20Recovery...

3/22/2005

Annual Cost Recovery Statement - Fye 9-30-04 - Alabama Wireless 9-1-1 Board