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                                                               RETURN OF E-911 SURCHARGE                                                                                                                 2021
                                          -  E-911 
                                             SURCHARGE         BY TELECOMMUNICATION PROVIDERS 
                                                               TITLE 11,               ADMINISTRATIVE CODE OF THE CITY OF NEW YORK

                                                               Period beginning ________-_________-________          Period ending ________-_________-________
                      Name:                                                                  Name                   EMPLOYER 
                                                                                             Change  n              IDENTIFICATION 
                      ____________________________________________________________________________________________  NUMBER: 
                       In Care of:                                                                                   OR
                                                                                                                     SOCIAL 
                     _____________________________________________________________________________________________  SECURITY 
                       Address (number and street):                                          Address                NUMBER: 
                                                                                             Change  n               
                     _____________________________________________________________________________________________   
                       City and State:                      Zip Code:                  Country (if not US):         FEDERAL 
          *90012191*                                                                                                BUSINESS 
                                                                                                                    CODE: 
                     _____________________________________________________________________________________________   
                       Business Telephone Number:           Taxpayer’s Email Address:                               2-CHARACTER SPECIAL CONDITION CODE                                      
                                                                                                                    IF APPLICABLE (SEE INSTRUCTIONS                             ):

 Check type of business entity:              n Corporation                    n Partnership                                                                                   n Individual 
                                                                                                                                                                                            Check this box if you have 
 Check type of return:                       n Initial return                 n Amended return                                                                                n Final return - ceased operations in NYC.

 Date business began: nn nn nnnn    -                    -                              Date business ended:nn nn nnnn   -                                                                    -

 SCHEDULE A                 Computation of E-911 Surcharge                             (See instructions)
                                                                                                                                                                                Payment Amount
                                                                                                                                                                               
 A.    Payment           Amount being paid electronically with this return ......................................................  A.

                     NUMBER OF LAND LINE DEVICES                       SURCHARGE AMOUNT PER DEVICE                                                                              SURCHARGE DUE 
 
1.                                                             X                             $1.00                         =                                               1. 
 
2. Less Administrative Fee (multiply line 1, surcharge due, by 2%)     ....................................................................................   2.                
 
3. Net Surcharge Due on Land Line devices (line 1 less line 2) .............................................................................................   3.               
 
   NUMBER OF VOICE OVER INTERNET PROTOCOL (VOIP) DEVICES               SURCHARGE AMOUNT PER DEVICE                                                                              SURCHARGE DUE 
 
4.                                                             X                             $1.00                         =                                               4. 
 
5. Less Administrative Fee (multiply line 4, surcharge due, by 2%)     ....................................................................................   5.                
 
6. Net Surcharge Due on VOIP devices (line 4 less line 5)   ........................................................................................................   6.       
 
7. TOTAL REMITTANCE DUE (Add lines 3 and 6).............................................................................................................................   7.

                                                    CERTIFICA TION OF T AXP A YER
 I hereby certify that this return, including any accompanying schedules or statements, has been                            Firm's Email Address 
 examined by me, and is, to the best of my knowledge and belief, true, correct and complete. 
 I authorize the Dept. of Finance to discuss this return with the preparer listed below. (see instructions) ..YES   n   ______________________________ 
                                                                                                                                                                                Preparer's Social Security Number or PTIN
 
Signature of owner, partner or officer of corporation Title                            Phone Number                Date 
                                                                                                                                                                                Firm's Employer Identification Number
Preparer's signature                                  Preparer’s printed name                                      Date 
                                                                                                                             
Firm's name (or yours, if self-employed)              Address                                                      Zip Code                                                     Check if self-employed:  n
                     SEE INSTRUCTIONS FOR MAILING AND P A YMENT INFORMA TION

90012191                                                                                                                                                                          NYC-E-911 SURCHARGE  2021



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                                                                                                  NEW YORK CITY DEPARTMENT OF FINANCE
 Instructions for Form NYC-E-911 Surcharge
IMPORTANT INFORMATION CONCERNING FORM                                Payments must be made in US dollars, drawn on a US bank.  
NYC-200V AND PAYMENT OF TAX DUE                                      Checks drawn on foreign banks will be rejected and returned.  
                                                                     Make your remittance payable to: NEW YORK CITY DEPART-
Payments may be made on the NYC Department of Finance web-           MENT OF FINANCE. 
site at nyc.gov/eservices, or via check or money order.  If paying    
with check or money order, do not include these payments with        For further information, call 311.  If calling from outside of the 
your New York City return.  Checks and money orders must be          five NYC boroughs, please call 212-NEW-YORK (212-639-
accompanied by payment voucher form NYC-200V and sent to             9675). 
                                                                      
the address on the voucher.  Form NYC-200V must be post-
                                                                     Preparer Authorization: If you want to allow the Department of 
marked by the return due date to avoid late payment penalties and 
                                                                     Finance to discuss your return with the paid preparer who signed 
interest.  See form NYC-200V for more information. 
                                                                     it, you must check the "yes" box in the signature area of the return.  
 
                                                                     This authorization applies only to the individual whose signature 
HIGHLIGHT OF RECENT LEGISLATIVE CHANGE 
                                                                     appears in the "Preparer’s Use Only" section of your return.  It 
As of December 1, 2017, the tax of 30 cents per month on every       does not apply to the firm, if any, shown in that section.  By check-
wireless communication device formerly imposed by Chapter 23-        ing the "Yes" box, you are authorizing the Department of Finance 
B of the Title 11 of the Administrative Code  is no longer admin-    to call the preparer to answer any questions that may arise during 
istered by New York City.                                            the processing of your return.  Also, you are authorizing the pre-
                                                                     parer to: 
                                                                      
Special Condition Codes 
                                                                     l Give the Department any information missing from the re-
At the time this form is being published, there are no applicable 
                                                                       turn, 
special condition codes for tax year 2020.  Check the Finance         
website for updated special condition codes. If applicable, enter    l Call the Department for information about the processing of 
the two character code in the box provided on the form.                your return of the status of your payment(s), and 
                                                                      
GENERAL  INFORMATION                                                 l Respond to certain notices that you have shared with the 
                                                                       preparer about math errors, offsets and return preparation.  
Section 11-2323 of the Administrative Code of the City of New          The notices will not be sent to the preparer. 
York imposes a surcharge of $1.00 (one dollar) per telephone ac-      
cess line per month on customers of every telephone service sup-     You are not authorizing the preparer to receive any refund check, 
plier within New York City.  Additionally a surcharge of $1.00       bind you to anything (including any additional E-911 surcharge 
(one dollar) per telephone access line, or equivalent, is also im-   amount due), or otherwise represent you before the Department.  
posed on customers of providers of voice over internet protocol      The authorization cannot be revoked, however, the authorization 
(“VOIP”) service within New York City.                               will automatically expire 90 days after the filing of the return.  
                                                                     Failure to check the box will be deemed a denial of authority. 
The surcharges shall be used to pay for the costs associated with     
the design, construction, operation, maintenance and administra-      
tion of public safety communications networks serving the City of    MAILING INSTRUCTIONS 
New York.  The surcharge is to be separately stated and added to 
every customer’s bill.  Each telephone service supplier and each                   MAIL ALL RETURNS      TO:
VOIP service provider that provides local access service within 
                                                                               NYC DEPARTMENT OF FINANCE 
the 911 service area in the City of New York is entitled to retain,                         E-911 
as an administrative fee, an amount equal to two percent of its                           P.O. BOX 5564 
collections of the surcharge.                                                  BINGHAMTON, NY 13902-5564
 
DEFINITIONS: 
 
“Voice over internet protocol service” or “VOIP service” means                                           
                                                                                   REMITTANCES
any service that (i) enables real-time, two-way communications; 
(ii) requires a broadband connection from the user’s location; (iii)        PAY ONLINE WITH FORM NYC-200V 
requires internet protocol compatible customer premises equip-                 AT NYC.GOV/ESERVICES 
ment (CPE); and (iv) permits users generally to receive calls that                          OR 
originate on the public switched telephone network and to termi-
                                                                       Mail Payment and Form NYC-200V ONLY to:  
nate calls to the public switched telephone network. 
                                                                               NYC DEPARTMENT OF FINANCE 
FILING A RETURN AND PAYMENT OF SURCHARGE                                                    E-911 
 
                                                                                          P.O. BOX 3933 
Returns are due on or before the 25th day of each month, cover-
ing surcharge monies collected for the preceding calendar month.               NEW YORK, NY 10008-3933






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