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REVISED OPERATIONAL SURCHARGE 911 SAMPLE STATEMENT |
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| Service Provider Name: | ||||||||
| Settlement Period (Quarterly): | ||||||||
| SAMPLE | ||||||||
| Community | Billing Month | Billing Month | Billing Month | |||||
| January | February | March | Total | Surcharge | ||||
| # of Devices | # of Devices | # of Devices | Devices |
Rate |
Due | |||
| Belleville | 22 | 10 | 15 | 47 | $0.42 | $ 19.74 | ||
| Canton Twp | 52 | 102 | 125 | 279 | $0.42 | $ 117.18 | ||
| Dearborn | ||||||||
| Dearborn Hts | ||||||||
| Garden City |
12 |
13 |
15 |
40 |
$0.42 | $ 16.80 | ||
| Huron Twp (New Boston) | ||||||||
| Inkster | ||||||||
| Livonia | ||||||||
| Northville | ||||||||
| Northville Twp |
11 |
15 |
14 |
40 |
$0.42 | $ 16.80 | ||
| Plymouth | ||||||||
| Plymouth Twp | ||||||||
| Redford Twp |
12 |
20 |
22 |
54 |
$0.42 | $ 22.68 | ||
| Romulus (Middlebelt) | ||||||||
| Sumpter Twp | ||||||||
| Van Buren Twp (Rawsonville) | ||||||||
| Wayne | ||||||||
| Wayne County Airport | ||||||||
| Westland (Eloise) |
10 |
15 |
18 |
43 |
$0.42 | $ 18.06 | ||
| SUBTOTAL | $ 211.26 | |||||||
| Less 2% Billing & Collection Fee (if applicable) | $211.26 x 2% | $ - 4.23 | ||||||
| TOTALS | 119 | 175 | 209 | 503 | $ 207.03 | |||
| Local Contact Name: | ||||||||
| Title: | ||||||||
| Address: | ||||||||
| Phone: | ||||||||
| Fax Number: | ||||||||
| email: | ||||||||
| Remit Check to: Wayne County Treasurers Office, Attn: Accounting Supervisor, 400 Monroe St. #540, Detroit, MI 48226 | ||||||||
| Remit Statement to BOTH addresses: 1)Conference of Western Wayne, 39293 Plymouth Rd., #101, Livonia, MI 48150 2) Wayne County Treasurers Office, Attn: Accounting Supervisor, 400 Monroe St., #540, Detroit, MI 48226 | ||||||||