Carrier Remittance Of Wireless E9-1-1 Funds Form printable pdf download

Carrier Remittance Of Wireless E9-1-1 Funds Form

UNOFFICIAL TEXT

Section 1000.APPENDIX B Format of Carrier Remittance Transmittal

CARRIER REMITTANCE OF WIRELESS E9-1-1 FUNDS

CARRIER NAME ______________________________

CARRIER FEIN # _________________________

CARRIER ADDRESS___________________________

CITY/ST/ZIP______________________________

CONTACT NAME______________________________

CONTACT PHONE # ______________________

REMITTANCE MONTH ________________________

REMITTANCE AMT $______________________

CHECK NUMBER _____________________________

CHECK DATE ____________________________

REMITTANCE MONTHLY BREAKDOWN:

MO/YR Billed

Amount Remitted

____/____

$______________.___

____/____

$ _____________.___

____/____

$ _____________.___

____/____

$ _____________.___

____/____

$ _____________.___

____/____

$ _____________.___

____/____

$ _____________.___

____/____

$_____________.___

TOTAL REMITTED

$_____________.___*

*Must agree with Remittance Amount listed at top of form

Section 1000.APPENDIX C Form of Sworn Statement

STATE OF ILLINOIS

)

SS.

COUNTY OF ____________ )

AFFIDAVIT

CONSULT OFFICIAL DOCUMENTS FOR OFFICIAL VERSION OF THESE RULES

Carrier Remittance Of Wireless E9-1-1 Funds Form