EVERETT PUBLIC SCHOOLS

I Certify No Instances of Personal Use:
I Certify and Claim Instances of Accidental or Emergency Personal Use:
1. Calculation of Payment

Cellular Telephone

Bill Review Form

· You have received this form because you have either exceeded your plan minutes, have an unusual usage pattern, or have notified us of accidental/emergency personal use.

· Please review your bill, sign one of the certifications below, and calculate amount owed, if applicable. Charges shall be assessed on all accidental/emergency personal calls, both out-going and incoming, at the rate of $5.00 per call for the first minute and $1.00 for each additional minute. All partial minutes shall be rounded up to the next whole minute.

· The bill, this form, and any personal payment owed, is due to Accounting within 7 days of receipt of the bill.

I Certify No Instances of Personal Use:

I certify that I have reviewed the attached cell phone bill and that all usage and charges on this bill are work related and conducted as part of my official duties as an employee for Everett Public Schools.

Cell Phone User Signature

Date

I Certify and Claim Instances of Accidental or Emergency Personal Use:

I certify that I have reviewed the attached cell phone bill and have highlighted all personal phone calls both incoming and outgoing. All other usage and charges on this cell phone bill are work related and conducted as part of my official duties as an employee for Everett Public Schools. I have enclosed my payment, as calculated below, to reimburse the District for any personal calls noted.

Calculation of Payment

First minute(s)/per call

x $5.00/per call: $

Each additional minute(s)

x $1.00: $

Total Payment: $

Cell Phone User Signature Date

BILL & FORM MUST BE RETURNED TO THE ACCOUNTING OFFICE WITHIN 7 DAYS OF RECEIPT OF BILL. YOUR PROMPT REVIEW IS APPRECIATED.

Rev. 02/14 1.03c