Carrier Remittance Of Wireless E9-1-1 Funds Form Page 2
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2UNOFFICIAL TEXT
The undersigned, being first duly sworn under oath, deposes and says, under penalties of
perjury:
1.
I am the _______________ [title of official making Affidavit] of ______________ [legal
name of Carrier] (the “Carrier”), a corporation [insert other business form, if applicable]
created and existing under the laws of the State of ____________, and am duly
authorized to make this Affidavit on behalf of the Carrier.
2.
This Affidavit is made for the purpose of requesting Reimbursement from the Wireless
Carrier Reimbursement Fund in the amount of $_______________ [amount of
reimbursement requested] pursuant to Section 35 of the Illinois Wireless Emergency
Telephone Safety Act (the “Act”).
3.
The amount requested is reimbursable under the Act.
4.
Attached hereto as Exhibit A is a list of the goods or services for which reimbursement
under this Affidavit is sought.
5.
Attached hereto as Exhibit B are copies of invoices supporting the Reimbursement
requested.
6.
All of the Reimbursement requested represents costs incurred by the Carrier in
complying with Federal Communications Commission Wireless Enhanced 9-1-1
mandates (“FCC Mandates”).
7.
Attached hereto as Exhibit C is an explanation of how the costs represented by the
attached invoices relate to compliance with the FCC Mandates described therein.
8.
I have read the Exhibits attached hereto and know them to be true and accurate.
9.
All Reimbursement requested hereunder represents costs that are related to compliance
with the requirements established by the FCC Mandates.
10.
The Reimbursement requested hereunder represents costs with respect to Wireless
Enhanced 9-1-1 service that is operable and capable of transmitting Wireless Enhanced
9-1-1 data.
11.
The following are the geographic areas, by zip code, receiving Wireless Enhanced 9-1-1
service as a result of the expenditures set forth in Exhibit B.
12.
To the best of my knowledge, the following are the Wireless Public Safety Answering
Points (as defined by the Act), receiving Wireless Enhanced 9-1-1 service as a result of
the expenditures set forth in Exhibit B.
13.
The Carrier is in compliance with the Act.
[Signature] ________________________________
[Printed Name of Official]
SUBSCRIBED AND SWORN TO this ______ day of ______, 200__ before me, a Notary Public
in and for the County and State aforesaid, by _____________ [name of official making Affidavit],
who is personally known to me to be the ______________ [affiant’s official title] of
______________ [legal name of Carrier] who appeared before me this day and duly
acknowledged to me execution of the foregoing Affidavit.
[Signature] ________________________________
Notary Public
[Seal]
CONSULT OFFICIAL DOCUMENTS FOR OFFICIAL VERSION OF THESE RULES
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