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CERTIFICATION <br />I, ________________ am authorized to sign this certification on behalf of _________________. <br /> (Insert name of local jurisdiction) <br />I certify to the following: <br />Please check all the following that apply to your jurisdiction: <br />1.___ 911 Charges/Access to Communication Services - Ordinance No. ____ of the <br />________________ imposes the local charge set forth in the ordinance to prepaid mobile <br /> (Insert name of local jurisdiction)telephony services for access to communication services or to local 911 emergency <br />telephone systems. As required by section 42102.5, the percentage reflecting the rate for <br />access to the local 911 emergency telephone systems or access to communications <br />services is ________. <br />2.___ Utility User Tax - Ordinance No. ____ of the ________________ imposes the local <br /> (Insert name of local jurisdiction)charge set forth in the ordinance to the consumption of prepaid mobile telephony <br />services. The tiered rate for the utility user tax, as identified in section 42102 is <br />___________. <br />3.The _________________ agrees to indemnify and to hold harmless the Board of <br />Equalization (Board), its officers, agents, and employees for any and all liability for <br />damages that may result from the Board’s collection pursuant to this agreement. <br />Executed in the _________________________________ on ___________________. <br /> (Insert name of local jurisdiction) (Add date) <br />Printed name ___________________________________ <br /> (Insert name of local jurisdiction) <br />Title of person ___________________________________ <br />Signature ___________________________________ <br />6.3.B. - Page 17