Section 729.APPENDIX C   Form of Sworn Statement

AFFIDAVIT

The undersigned, being first duly sworn under oath, deposes and says, under penalties of perjury:

1.       I am the [title of official making Affidavit] of [legal name of Carrier] (the "Carrier"), a corporation [insert other business form, if applicable] created and existing under the laws of the State of _______________________, and am duly authorized to make this Affidavit on behalf of the Carrier.

2.       This Affidavit is made for the purpose of requesting Reimbursement from the Wireless Carrier Reimbursement Fund in the amount of $ [amount of reimbursement requested] pursuant to Section 35 of the Illinois Wireless Emergency Telephone Safety Act (Act).

3.       The amount requested is reimbursable under the Act.

4.       Attached as Exhibit A is a list of the goods or services for which reimbursement under this Affidavit is sought.

5.       Attached as Exhibit B are copies of invoices supporting the Reimbursement requested.

6.       All of the Reimbursement requested represents costs incurred by the Carrier in complying with Federal Communications Commission Wireless Enhanced 9-1-1 mandates (FCC Mandates).

7.       Attached as Exhibit C is an explanation of how the costs represented by the attached invoices relate to compliance with the FCC Mandates.

8.       I have read the attached Exhibits and know them to be true and accurate.

9.       The Reimbursement requested represents costs with respect to Wireless Enhanced 9-1-1 service that is operable and capable of transmitting Wireless Enhanced 9-1-1 service as a result of the expenditures set forth in Exhibit B.

10.       To the best of my knowledge, the following are the Wireless Public Safety Answering Points (as defined by the Act) receiving Wireless Enhanced 9-1-1 service as a result of the expenditures set forth in Exhibit B.

11.       The Carrier is in compliance with the Act.