FCC Form 499-Q Telecommunications Reporting Worksheet

FCC Form 499-Q Telecommunications Reporting Worksheet
Quarterly Filing for Universal Service Contributors
Block 1:

>>> Please read instructions before completing <<<
101

Contributor Identification Information

102

Legal name of reporting entity

103

IRS employer identification number

104

Name telecommunications provider is doing business as

105

Holding company [All affiliated companies should show same name here.]

106

FCC Registration Number (FRN)

107

Complete mailing address of reporting entity's
corporate headquarters

Block 2:

Approval by OMB
3060-0855

Filer 499 ID

Contact Information
First

MI

108

Person who completed this worksheet

109

Telephone number of this person

(

) -

110

Fax number of this person

(

) -

111

Email of this person

112

Billing address and billing contact person:

Last

[Bills for Universal Service contributions
will be sent to this address.]
Block 3:

Contributor Historical and Projected Revenue Information

113

Year of historical revenue information
Filing due

Historical revenues for

Projected revenues for

114

Indicate which

October 1 - December 31 (prior year)

April 1 - June 30
July 1 - September 30

February 1

quarterly filing

May 1

January 1 - March 31

this represents

August 1

April 1 - June 30

October 1 - December 31

November 1

July 1 - September 30

January 1 - March 31 (following calendar year)

Historical billed revenues with no allowance or
deductions for uncollectibles. See instructions.
115

Total
Revenues
(a)

Interstate
Revenues
(b)

117

Telecommunications provided to other universal service
contributors for resale as telecommunications or as
interconnected VoIP
End-user telecommunications revenues including any
pass-through charges for universal service contributions,
but excluding international-to-international revenues
All other goods and services

118

Gross-billed revenues from all sources [sum of above]

119

Projected gross-billed end-user interstate and international telecommunications
revenues including any pass-through charges for universal service contributions, but
excluding international-to-international revenues
Projected collected end-user interstate and international telecommunications
revenues including any pass-through charges for universal service contributions, but
excluding international-to-international revenues

116

120

International
Revenues
(c)

Column (b) and (c) not requested
for Lines 117 and 118

Block 4: CERTIFICATION: to be signed by an officer of the reporting entity

121

I certify that the revenue data contained herein are privileged and confidential and that public disclosure of such information
would likely cause substantial harm to the competitive position of the company. I request nondisclosure of the revenue
information contained herein pursuant to sections 0.459, 52.17, 54.711 and 64.604 of the Commission's Rules.

I certify that I am an officer of the above-named reporting entity, that I have examined the foregoing report and to the best of my knowledge,
information and belief, all statements of fact contained in this Worksheet are true, that said Worksheet is an accurate statement of the affairs of
the above-named company for the quarter and that the projections of gross-billed and collected revenues represent a good-faith estimate
based on company procedures and policies.
122

Signature

123

Printed name of officer

124

Position with reporting entity

125

Email of officer

126

Date

127

This filing is:

First

MI

Last

|| Required if available ||
Original filing

Revised filing [revisions due within 45 days of original filing deadline]

Do not mail checks with this form. Send this form to: Form 499 Data Collection Agent c/o USAC 2000 L Street, N.W. Suite 200 Washington DC, 20036
For additional information regarding this worksheet contact: Telecommunications Reporting Worksheet Info: (888) 641-8722 or via e-mail: [email protected]
PERSONS WILLFULLY MAKING FALSE STATEMENTS IN THE WORKSHEET CAN BE PUNISHED BY FINE OR IMPRISONMENT UNDER TITLE 18 OF THE UNITED STATES CODE, 18 U.S.C. §1001

Save time, avoid problems -- file electronically at

http://forms.universalservice.org

FCC Form 499-Q
February 2010