Ron Sleeper, Chairman
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Johnny Hart, Vice-Chairman |
Bill Brodeur, Secretary/Treasurer
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Roger Wilson |
Leslie Bonet |
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Sen. Bobby Singleton |
Rep. Tommy Sherer |
REQUEST FOR REIMBURSEMENT OF RECURRING AND
NONRECURRING COSTS FOR IMPLEMENTATION OF E9-1-1, PHASE I
PROVIDER:____________________________________________________________________
CONTACT:_______________________________________________PHONE:______________
ADDRESS:_____________________________________________________________________
______________________________________________________________________ ______________________________________________________________________
In accordance with Ala.Code Sec. 11-98-7 & Reg. 225-1-.03-.05 and the agreement for cost recovery, we request the following reimbursement for implementation of wireless E9-1-1 service in Alabama from the Alabama Wireless 9-1-1 Board.
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Recurring Costs for period ______________to ______________ |
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$ |
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Nonrecurring Costs |
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Total Reimbursement Requested |
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$ |
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CERTIFICATION
I certify that this claim is correct and valid and is a proper charge against the Alabama Wireless 9-1-1 Board. Pursuant to the provisions of Ala. Code Sec 11-98-7, I certify that the amount claimed was incurred for the actual costs of complying with the wireless E-9-1-1 service requirements established by the FCC Order and any rules and regulations which are or may be adopted by the FCC pursuant to the FCC Order, including, but not limited to, costs and expenses incurred for designing, upgrading, purchasing, leasing, programming, installing, testing, or maintaining all necessary data, hardware, and software required in order to provide the service as well as the incremental costs of operating the service.
_______________________________________________ Date ______________________________
Signature of Carrier (Month, Day, Year)
_______________________________________________
Title
STATE
OF
COUNTY
OF
I,
the undersigned, a Notary Public in and for said County in said State, hereby
certify that __________________________, whose name as ________________________
of ___________________________ is signed to the foregoing conveyance, and who
is known to me, acknowledged before me that, being informed of the contents of
the conveyance, he, in his capacity as such _________________________________,
executed the same voluntarily for and as the act of said
_________________________ of the day that same bears date.
Given under my
hand this ______ day of
________________________________.
__________________________________________________
NOTARY
PUBLIC
MY COMMISSION EXPIRES:________________________