Caddo 9-1-1 Remittance Form
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1(Telephone Company's Name)
CADDO 9-1-1 REMITTANCE
Date: __________________________
Caddo Parish Communications
District Number One
Attn: Martha Carter
1144 Texas Avenue
Shreveport, LA 71101-3343
Enclosed you will find check number XXXXX in the amount of $XX,XXX.XX for the Caddo Parish 9-
1-1 Surcharge for the time period indicated below:
Time Period Covered:
Month, Day, Year through Month, Day Year
Total Wireline Business Customers Billed: XX,XXX
x
$2.00 =
$XX,XXX.XX
Total Wireline Residential Customers Billed: XX,XXX
x
$1.00 =
$XX,XXX.XX
(or)
Total Wireless Customers Billed:
XX,XXX
x
$1.00 =
$XX,XXX.XX
Less Administrative Fee (1% of Total)
(XX,XXX.XX)
Total Surcharge Remittance
$XX,XXX.XX
Should you have any questions regarding this remittance, please do not hesitate to contact me.
You may reach me at (contact telephone number & extension, email, fax, etc.)
Sincerely,
Name of Person Mailing Remittance
Title
Address
City ST Zip
Enclosure (Check)
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