Form Nyc-E-911 - Return Of E-911 Surcharge By Telecommunication Providers - 2018
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1
2- E-911
RETURN OF E-911 SURCHARGE
2018
BY TELECOMMUNICATION PROVIDERS
TM
SURCHARGE
Department of Finance
TITLE 11, ADMINISTRATIVE CODE OF THE CITY OF NEW YORK
Period beginning ________-_________-________
Period ending ________-_________-________
Name:
n
Name
EMPLOYER
Change
IDENTIFICATION
:
____________________________________________________________________________________________
NUMBER
In Care of:
OR
SOCIAL
_____________________________________________________________________________________________
SECURITY
n
:
Address (number and street):
Address
NUMBER
Change
_____________________________________________________________________________________________
FEDERAL
City and State:
Zip Code:
Country (if not US):
BUSINESS
:
CODE
_____________________________________________________________________________________________
-
Business Telephone Number:
Taxpayer’s Email Address:
2
CHARACTER SPECIAL CONDITION CODE
(
):
IF APPLICABLE
SEE INSTRUCTIONS
n
n
n
Check type of business entity:
Corporation
Partnership
Individual
n
n
n
Check type of return:
Initial return
Amended return
Final return
nn-nn-nnnn
nn-nn-
nnnn
Date business began:
Date business ended:
S C H E D U L E A
Computation of E-911 Surcharge
(See instructions)
Payment Amount
Payment
A.
A.
Amount being paid electronically with this return
NUMBER OF LAND LINE DEVICES
SURCHARGE AMOUNT PER DEVICE
SURCHARGE DUE
=
1.
X
$1.00
1.
2. Less Administrative Fee (multiply line 1, surcharge due, by 2%)
2.
....................................................................................
3. Net Surcharge Due on Land Line devices (line 1 less line 2)
3.
.............................................................................................
NUMBER OF VOICE OVER INTERNET PROTOCOL (VOIP) DEVICES
SURCHARGE AMOUNT PER DEVICE
SURCHARGE DUE
=
4.
X
$1.00
4.
5. Less Administrative Fee (multiply line 4, surcharge due, by 2%)
5.
....................................................................................
6. Net Surcharge Due on VOIP devices (line 4 less line 5)
6.
........................................................................................................
7. TOTAL REMITTANCE DUE (Add lines 3 and 6)
7.
.............................................................................................................................
C E R T I F I C A T I O N
O F
T A X P A Y E R
Firm's Email Address
I hereby certify that this return, including any accompanying schedules or statements, has been
examined by me, and is, to the best of my knowledge and belief, true, correct and complete.
______________________________
n
I authorize the Dept. of Finance to discuss this return with the preparer listed below. (see instructions) ..YES
Preparer's Social Security Number or PTIN
Signature of owner, partner or officer of corporation
Title
Phone Number
Date
Firm's Employer Identification Number
Preparer's signature
Preparer’s printed name
Date
n
Firm's name
Address
Zip Code
(or yours, if self-employed)
Check if self-employed:
S E E I N S T R U C T I O N S F O R M A I L I N G A N D P A Y M E N T I N F O R M A T I O N
90011891
NYC-E-911 SURCHARGE 2018
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