Form Boe-501-Te - Emergency Telephone Users Surcharge Return Page 2

Download a blank fillable Form Boe-501-Te - Emergency Telephone Users Surcharge Return in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Boe-501-Te - Emergency Telephone Users Surcharge Return with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

BOE-501-TE (BACK) REV. 12 (4-13)

INSTRUCTIONS

EMERGENCY TELEPHONE USERS SURCHARGE RETURN

Payments: You can make your payment by paper check, Online ACH Debit (ePay) or by credit card. To use ePay, go to our

website at , click on the eServices tab and log in to make a payment. To pay by credit card, go to our

website or call 1-855-292-8931. Mandatory EFT accounts must pay by EFT or ePay. Be sure to sign and mail your return.

PREPARATION OF THE RETURN

Line 1.

Enter the total charges due from service users for all telecommunication services subject to the surcharge other than

charges for VoIP services.

Enter the total charges due from service users for all telecommunication services subject to the surcharge for VoIP

Line 2.

services only.

Line 3.

Enter the total charges for services subject to the surcharge by adding lines 1 and 2.

For lines 1, 2, and 3, if you have contracted with a billing aggregator to collect some or all of your telephone charges,

include only the charges that you billed to the customers. Surcharge amounts on charges billed by an authorized

billing aggregator will be reported by the billing aggregator. If a billing aggregator remits only a portion of your

surcharge liability, you remain responsible to remit the balance of the surcharge due.

Line 4.

Current rate of surcharge, as set pursuant to section 41031 of the Emergency Telephone Users Surcharge Law.

Enter the total amount of surcharge by multiplying the charges for services subject to the surcharge on line 3 by the

Line 5.

surcharge rate on line 4.

Line 6.

Enter the amount of surcharge you were unable to collect from service users during the reporting period because of

specific refusals to pay the surcharge. Attach a list of service users who have refused to pay a cumulative total of

$3.00 or more in surcharges. The list must include the name and address of each refuser, the amount of surcharge

not paid, and the date it was billed. Also provide each service user's stated reason for refusing to pay the surcharge.

Line 7.

Subtract line 6 from line 5 and enter total amount of surcharge due.

Lines 8

If the surcharge is paid after the due date shown on the front of this return, additional amounts are due for penalty

and interest charges.

and 9.

Line 10.

Enter total amount due and payable, including late charges, if applicable, by adding lines 7, 8, and 9.

POWER OF ATTORNEY

Billing aggregator authorization to collect and remit the Emergency Telephone Users Surcharge (surcharge) and consent

to disclose information to the BOE about services performed by the billing aggregator for the service supplier.

Name of service supplier and account number under the Emergency Telephone Users Surcharge Law (Service Supplier)

appoints

Name of Billing Aggregator registered with the BOE (Billing Aggregator)

as attorney-in-fact authorized to receive call information detail from the Service Supplier and submit that call information

detail to one or more local exchange carriers acting as billing agents, receive payments from local exchange carriers

acting as billing agents for disbursement as directed by the Service Supplier, and prepare and file returns and remit the

surcharge to the BOE. The Billing Aggregator is authorized to file a separate return for the Service Supplier or file a single

return for more than one Service Supplier. The Service Supplier also consents for the Billing Aggregator to disclose to the

BOE any and all records concerning the activities conducted on behalf of the Service Supplier related to the surcharge.

This authorization shall remain in effect until superceded by a letter of writing filed with the BOE, or until revoked by the

Service Supplier.

Signature of Service Supplier's Authorized Representative

Printed Name and Title of Signer

Date

Signature of Billing Aggregator's Authorized Representative

Printed Name and Title of Signer

If you need additional information, please contact the State Board of Equalization, Special Taxes and Fees, P.O. Box 942879, Sacramento, CA 94279-0088. You

may also visit the BOE website at or call the Taxpayer Information Section at 1-800-400-7115 (TTY:711); from the main menu, select the option

Special Taxes and Fees.

CLEAR