Form 5012 - Retailer'S Prepaid Wireless 9-1-1 Surcharge - Michigan Department Of Treasury
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Michigan Department of Treasury
5012 (1-13)
Retailer’s Prepaid Wireless 9-1-1 Surcharge
PART 1: GENERAL INFORMATION
Effective January 1, 2013, a seller is required to collect a 9-1-1 surcharge of 1.92% on retail transactions occurring in Michigan for
prepaid wireless telecommunication services. A prepaid wireless telecommunication service means:
“A commercial mobile radio service that allows a caller to dial 9-1-1 to access the 9-1-1 system and is paid for in
advance and sold in predetermined units or dollars of which the number declines with use in a known amount.”
Seller’s must disclose to the consumer or separately itemize the 9-1-1 surcharge on an invoice, receipt or other similar document. A
seller is not required to collect the surcharge if the wireless services sold with a prepaid wireless device and the service denominated is
10 minutes or less, or for $5.00 or less.
If the prepaid wireless telecommunications service is sold with one or more products or services for a single, nonitmeized price, the
1.92% surcharge will apply to the full retail amount unless:
1) The prepaid wireless service amount is disclosed to the consumer at the time of purchase.
2) The seller can identify the wireless service price in their records by reasonable and verifi able standards.
If the wireless service price included in a packaged retail sale is determined by either of the above two methods, the 1.92% surcharge
applies only to the disclosed or identifi able amount.
Use this form to report the prepaid wireless 9-1-1 surcharges collected. Payment by check should be enclosed with this return. If
electing to pay using Electronic Funds Transfer (EFT), you must still complete and mail this form to the address provided within 30 days
of the close of the period you are reporting.
PART 2: ACCOUNT INFORMATION
Business Name
Federal Employer Identifi cation Number (FEIN)
Business Address (Street Number, P.O. Box)
City, State, Zip Code
Contact Person
Contact Telephone Number
Year
Filing Period Month
PART 3: RETAILER’S 9-1-1 SURCHARGE
1.
Enter Total Prepaid Wireless Retail Sales subject to surcharge. .............................................................
1.
2.
Enter the Prepaid Wireless 9-1-1 Surcharge. Multiply Line 1 by 1.92% (.0192). ......................................
2.
3.
Enter Allowable Amount the seller may retain. Multiply Line 2 by 2% (.02). ............................................
3.
4.
Enter Total Retailer 9-1-1 Surcharge due. Subtract Line 3 from Line 2. Pay this amount. .....................
4.
5.
Total payment enclosed with this return. ....................................................................................................
5.
PART 4: CERTIFICATION
I declare under penalty of perjury that the information on this form is true and complete to the best of my knowledge.
Signature
Telephone Number
Date
PART 5: INSTRUCTIONS
Account Information. Complete all requested information. Enter the
Payment. Enclosed payments should be made payable to the
month and year in which the retail sales reported on the form occurred.
State of Michigan. Write your FEIN and “911 Charges” on the front
of your payment. If you elect to transmit payments using Electronic
Line 1. Enter total retail transactions amount subject to the prepaid
Funds Transfer (EFT), visit
wireless telecommunication service surcharge.
for EFT registration and payment information. A copy of this form
Line 2. Multiply the total prepaid wireless retail sales subject to surcharge
and full payment is due to Treasury within 30 days of the close
(Line 1) by the prepaid wireless surcharge rate of 1.92% (.0192)
of each month. Receipt of a completed Form 5012 is required
Line 3. Multiply the prepaid wireless 9-1-1 surcharge (Line 2) by 2%
regardless of payment method.
(.02). This amount may be retained by the seller for the costs incurred
for the billing and collection of the surcharge.
Return Completed Form and Check Payment to:
Line 4. Subtract the allowable retained amount (Line 3) from the
Michigan Department of Treasury
surcharge collected (Line 2). This is your payment due.
P.O. Box 30427
Line 5. Enter the total payment enclosed with the return. Enter $0.00
Lansing, Michigan 48909-7927
if you are not including payment or remit payments using Electronic
For questions regarding the Retailer’s Prepaid Wireless 9-1-1
Funds Transfer (EFT).
Surcharge, call (517) 636-6925.
Certifi cation. You must sign and date the return. Please include a
contact phone number.
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