NCC204883_Annual Fee Payment Record_20211102

Action History (UTC-05:00) Eastern Time (US & Canada)
by Workflow 9/30/2021 1:43:14 PM (Workflow Start Event)
Submit by Selkane, Aziza 11/2/2021 4:29:30 PM (2021 Annual Fee Payment Verification for NCC204883-2021)
0 Daniel Whitley
• Selkane, Aziza assigned the task to Selkane, Aziza 11/2/2021 4:28 PM
• The task was assigned to DEMLR NCG01 Annual Fee Team. The due date is: November 11, 2021 5:00
PM 9/30/2021 1:43 PM

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NORTH CAROLINA
Envlrmmm(af Quafhy
Certificate of
NCC204883
Coverage (COC) No. *
This is passed from the workflow when the invoice is filed.
NC Reference COC
NCG01-2020-4883
No. *
Permit Status:
Active
Year COC Issued
2020
This field will be hidden.
2020 Fee Status
Check last year's fee status
Project Name*
Eastern Carolina Dental
Project Address*
56 Office Park Drive, Jacksonville, NC
Permittee*
Daniel Whitley, III, DDS, PA
County
Onslow
Invoice No.*
NCC204883-2021
This is passed from the workflow when the invoice is fled.
Annual Fee*
$ 100.00
Invoice Date*
10/1/2021
This is passed from the workflow when the invoice is filed.
Invoice Due Date*
11/1/2021
This is passed from the workflow when the invoice is filed.
An automated email reminder is sent to the permittee when the invoice is due. Wait until invoice is 15 days overdue
before proceeding to a Notice of Deficiency.
Days Overdue
1
Wait at least 15 days until proceeding to NOD.
Important: If you change the choice below to Payment NOT RECEIVED, the fee status becomes PAST DUE, and the
permittee will receive a Notice of Deficiency.
Annual Fee Payment
• Fee Payment Received or Not Applicable.
Received*
Fee Payment NOT RECEIVED.
Date Payment
11/2/2021
Received *
Or, if WAIVED or NOT RECEIVED, this is the date that status is recorded.
Method of Payment*
• electronic
check
other

ePayment 600741724
Transaction Number*
Fee Status* PAID
Legally Responsible Daniel Whitley
Person (Orig.)
Original Permittee E- [e-mail]
mail *
CONFIRM Permittee [e-mail]
E-mail * Opportunity to modify problem e-mail address or permittee contact info
Original Site Contact [e-mail]
E-mail *
CONFIRM Site [e-mail]
Contact E-mail * Opportunity to correct problem e-mail address or site contact info
Original Billing E-mail (If available)
CONFIRM Billing E- Opportunity to correct problem e-mail address or billing contact info
mail
Billing Telephone No.
Permittee Email for [e-mail]
30-day Reminder This is the email for the 30-day reminder if needed (passed from workflow).
Site Contact Email for [e-mail]
30-day Reminder This is the email for the 30-day reminder if needed (passed from workflow)
Billing Contact Email This is the email for the 30-day reminder if needed (passed from workflow).
for 30-day Reminder
Additional Billing Contact E-mails
Additional E-mail for
CC:
Review Date* 11/2/2021