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Form BOE-501-TE Fillable Emergency Telephone Users Surcharge Return
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)$3 00 or more in surcharges The list must include the name and address of each refuser the amount of surcharge (1 Total charges for all intrastate telecommunication services subject to the surcharge excluding charges for VoIP services (see instructions) $ ) (10 TOTAL AMOUNT DUE AND PAYABLE (add lines 7 8 and 9) $) (2 Total charges for VoIP intrastate telecommunication services subject to the surcharge only (see instructions) $) (3 Total charges for services subject to surcharge (add lines 1 and 2) $) (4 Rate of surcharge $) (5 Total amount of surcharge (multiply line 3 by line 4) $) (6 Total surcharge which service users have refused to pay (attach documentation) $) (7 Surcharge due and payable (subtract line 6 from line 5) $) (8 PENALTY [Multiply line 7 by 10% (0 10) or $10 00 whichever is greater if payment is made after due date shown above] $) (9 INTEREST $ ) (9 INTEREST: One month's interest is due on the surcharge for each month or fraction of a month that payment is delayed after the due date The adjusted monthly interest rate is ) (ADDRESS) (BILLING AGGREGATOR'S NAME) (BOE USE ONLY ) (CLEAR) CLEAR (Date) (DATE) (DUE ON OR BEFORE) (EMAIL ADDRESS) (Name of Billing Aggregator registered with the BOE (Billing Aggregator)) (Name of service supplier and account number under the Emergency Telephone Users Surcharge Law (Service Supplier)) (PRINT NAME AND TITLE) (PRINT) PRINT (Printed Name and Title of Signer) (TELEPHONE (AREA CODE)) (TELEPHONE ) (TELEPHONE NUMBER (AREA CODE)) (TELEPHONE NUMBER) (text) (text) (text) (text) (YOUR ACCOUNT NO ) [ FOID 1 Total charges for all intrastate telecommunication services subject to the surcharge 10 10 TOTAL AMOUNT DUE AND PAYABLE (add lines 7 8 and 9) $ 00 2 Total charges for VoIP intrastate telecommunication services subject to the surcharge 3 3 Total charges for services subject to surcharge (add lines 1 and 2) 4 4 Rate of surcharge 5 5 Total amount of surcharge (multiply line 3 by line 4) 6 6 Total surcharge which service users have refused to pay (attach documentation) 7 7 Surcharge due and payable (subtract line 6 from line 5) 8 Penalty [multiply line 7 by 10% (0 10) or $10 00 whichever is greater if payment is made 8 PENALTY 00 9 INTEREST 9 INTEREST: One month's interest is due on the surcharge for each month or fraction of a month that acting as billing agents for disbursement as directed by the Service Supplier and prepare and file returns and remit the after due date shown above] aggregator you need not submit again unless you revoke the Power of Attorney or change billing aggregators YOU MUST REPORT ALL Always write your account number on your check or money order Make a copy of this document for your records AMOUNTS REMITTED BY BILLING AGGREGATOR TO BE CREDITED TO SERVICE SUPPLIER ACCOUNT and interest charges appoints as attorney in fact authorized to receive call information detail from the Service Supplier and submit that call information billing aggregator and credited to your account for any periods during which the Power of Attorney remains in effect If you revoke the authority Billing aggregator authorization to collect and remit the Emergency Telephone Users Surcharge (surcharge) and consent billing aggregator will be reported by the billing aggregator If a billing aggregator remits only a portion of your BILLING AGGREGATOR'S NAME ADDRESS TELEPHONE NUMBER BOARD OF EQUALIZATION BOE 501 TE (FRONT) REV 12 (4 13)STATE OF CALIFORNIA BOE any and all records concerning the activities conducted on behalf of the Service Supplier related to the surcharge BOE USE ONLYRA B/A AUDREG charges charges for VoIP services collect the surcharge from each service user and remit to the state the amount of the surcharge detail to one or more local exchange carriers acting as billing agents receive payments from local exchange carriers DUE ON OR BEFORE EMAIL ADDRESS EMERGENCY TELEPHONE USERS SURCHARGE RETURN excluding charges for VoIP services (see instructions) $ FILING REQUIREMENTS For lines 1 2 and 3 if you have contracted with a billing aggregator to collect some or all of your telephone charges GENERAL INFORMATION I hereby certify that this return including any accompanying schedules and statements has beenexamined by me and to the best of my knowledge and belief is a true correct and complete return If the surcharge is paid after the due date shown on the front of this return additional amounts are due for penalty If you use a billing aggregator for some or all of your charges check here include only the charges that you billed to the customers Surcharge amounts on charges billed by an authorized including VoIP charges and to remit the surcharge that applies to these charges to the BOE In order to receive credit for the payment of the INSTRUCTIONSEMERGENCY TELEPHONE USERS SURCHARGE RETURN Line 1 Enter the total charges due from service users for all telecommunication services subject to the surcharge other than Line 10 Enter total amount due and payable including late charges if applicable by adding lines 7 8 and 9 Line 2 Enter the total charges due from service users for all telecommunication services subject to the surcharge for VoIP Line 3 Enter the total charges for services subject to the surcharge by adding lines 1 and 2 Line 4 Current rate of surcharge as set pursuant to section 41031 of the Emergency Telephone Users Surcharge Law Line 5 Enter the total amount of surcharge by multiplying the charges for services subject to the surcharge on line 3 by the Line 6 Enter the amount of surcharge you were unable to collect from service users during the reporting period because of Line 7 Subtract line 6 from line 5 and enter total amount of surcharge due Lines 8and 9 Make check or money order payable to State Board of Equalization must be filed even though you have no surcharge to report or if you utilize a billing aggregator to remit your surcharge liability on your behalf in Name of Billing Aggregator registered with the BOE (Billing Aggregator) Name of service supplier and account number under the Emergency Telephone Users Surcharge Law (Service Supplier) not paid and the date it was billed Also provide each service user's stated reason for refusing to pay the surcharge of the billing aggregator to remit the surcharge on your behalf you must notify the BOE in writing only (see instructions) 00 P O BOX 942879 payment is delayed after the due date The adjusted monthly interest rate is POWER OF ATTORNEY Power of Attorney form on the back of this return Once you have submitted a completed Power of Attorney designating the billing PREPARATION OF THE RETURN Printed Name and Title of Signer return for more than one Service Supplier The Service Supplier also consents for the Billing Aggregator to disclose to the RR QS FILEREF SACRAMENTO CA 94279 6091 section 41001 et seq ) The surcharge is imposed on amounts paid by every person in the state for intrastate telephone communication Service Supplier services and Voice over Internet Protocol (VoIP) services The service supplier (or billing aggregator authorized by a service supplier) shall services only Signature of Billing Aggregator's Authorized Representative Signature of Service Supplier's Authorized Representative SIGNATUREPRINT NAME AND TITLE SPECIAL TAXES AND FEES specific refusals to pay the surcharge Attach a list of service users who have refused to pay a cumulative total of SURCHARGE AMOUNTS COLLECTED BY YOU ON THIS RETURN Amounts collected on your behalf will be reported on a return filed by the surcharge liability you remain responsible to remit the balance of the surcharge due surcharge rate on line 4 surcharge to the BOE The Billing Aggregator is authorized to file a separate return for the Service Supplier or file a single surcharge you must list on the line below the name of the billing aggregator authorized to make payment for you and complete and sign the TELEPHONE( ) The California State Board of Equalization (BOE) administers the Emergency Telephone Users Surcharge Law (Revenue and Taxation Code The return must be filed on or before the date shown above A remittance for the amount due as shown must accompany the return This return the specific reporting period shown on the front of this return If you do not file a return on time you will be subject to penalty and interest This authorization shall remain in effect until superceded by a letter of writing filed with the BOE or until revoked by the to disclose information to the BOE about services performed by the billing aggregator for the service supplier You may contract with a billing aggregator registered with the BOE to collect some or all of your intrastate telephone communication charges YOUR ACCOUNT NO