CMRS Provider Remittance Form

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CMRS Provider Remittance Form Powered By Docstoc
					                                    CMRS Provider Remittance Form

Effective August 15, 1998, all CMRS providers, as defined in KRS.7635, Section 1, are required to collect
a fee from each subscriber with a billing address in Kentucky. Pursuant to KRS 65.7639, the following
information pertaining to the number of subscribers is considered proprietary information and will not be
released as a public record.

                                Make check payable to and submit to:
                                      Kentucky State Treasury
                         CMRS Emergency Telecommunications Board of Kentucky
                                          200 Mero Street
                                        Frankfort, KY 40601

From:                      _____________________________________________




Contact Name:              _____________________________________________

Contact Phone:             _____________________________________________

The following is a reporting for the period: ____________________

                  Total Subscribers: _______________________

(portion from total of billed subscribers_________, portion from total of pre-paid subscribers_________)

                  Fee:                        x.70

                  Total Collections: ________________________

                  Minus Cost of Collection (1.5%): ___________

                  Total Remittance:    _______________________

                  # of Discrepancies: _______________________ (provide name and number)
                           (discrepancies are subscribers who refuse to pay)

** A CMRS Provider may keep up to one and one-half (1.5%) of the emergency wireless enhanced 911 fee
collected each month from subscribers for the purpose of defraying the cost of collecting the fee.

I certify to the best of my knowledge and belief that the foregoing remittance is accurate and is the correct
amount due.

Name (printed)___________________________            Title:_________________________

Signature________________________________             Date:_________________________

Updated April 16, 2007                                                          This form may be reproduced

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