FCC Form 499A Telecommunications Reporting Worksheets - Annual

2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues)
>>> Please read instructions before completing. <<<
Annual Filing -- due April 1, 2011
Block 1: Contributor Identification Information
101

Approval by OMB
3060-0855

During the year, filers must refile Blocks 1, 2 and 6 if there are any changes in Lines 104 or 112. See Instructions.

Filer 499 ID [If you don't know your number, contact the administrator at (888) 641-8722.
If you are a new filer, write "NEW" in this block and a Filer 499 ID will be assigned to you.]

102

Legal name of reporting entity

103

IRS employer identification number

104

Name telecommunications provider is doing business as

105

Telecommunications activities of filer [Select up to 5 boxes that best describe the reporting entity. Enter numbers starting with "1" to show the order of importance -- see instructions.]

[Enter 9 digit number]

Audio Bridging (teleconferencing) Provider

CAP/CLEC

Incumbent LEC

Interconnected VoIP

Interexchange Carrier (IXC)

Paging & Messaging

Payphone Service Provider

Shared-Tenant Service Provider / Building LEC
If Other Local, Other Mobile or Other Toll is checked

Cellular/PCS/SMR (wireless telephony incl. by resale)

Coaxial Cable

Local Reseller

Operator Service Provider (OSP)

Prepaid Card

Private Service Provider

Satellite Service Provider

SMR (dispatch)

Toll Reseller

Wireless Data

Other Local

Other Mobile

Other Toll

describe carrier type / services provided:
106.1

Holding company name (All affiliated companies must show the same name on this line.)

106.2

Holding company IRS employer identification number

[Enter 9 digit number]

107

FCC Registration Number (FRN) [https://fjallfoss.fcc.gov/coresWeb/publicHome.do]
[For assistance, contact the CORES help desk at 877-480-3201 or [email protected]]

[Enter 10 digit number]

108
109

Management company [if filer is managed by another entity]
Complete mailing address of reporting entity
corporate headquarters

110

Complete business address for customer inquiries and complaints
check if same address as Line 109

Street1
Street2
Street3
City
Street1
Street2
Street3
City

(

State

Zip (postal code)

Country if not USA

State

Zip (postal code)

Country if not USA

111

Telephone number for customer complaints and inquiries [Toll-free number if available]

)

-

ext -

112

List all trade names used in the past 3 years in providing telecommunications. Include all names by which you are known by customers.
a
g
b
h
c
i
d
j
e
k
f
l
Use an additional sheet if necessary. Each reporting entity must provide all names used for telecommunications activities.

PERSONS MAKING WILLFUL 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-A / March 2011

2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues)

Page 2

Block 2-A: Regulatory Contact Information
201
202
203
204
205
206
207

Filer 499 ID [from Line 101]
Legal name of reporting entity [from Line 102]
Person who completed this Worksheet
Telephone number of this person
Fax number of this person
Email of this person || not for public release ||
Corporate office, attn. name, and mailing
address to which future Telecommunications
Reporting Worksheets should be sent
check if same name as Line 203
check if same address as Line 109

208

Billing address and billing contact person
[Plan administrators will send bills for contributions to this
address. Please attach a written request for alternative
billing arrangements. ]
check if name and address same as Line 207

First

MI

(
(

Block 2-B: Agent for Service of Process

Last

-

Office

ext -

Attn: First name
Phone

Email ||not for public release||
Street1
Street2
Street3
City

State

MI

(

)

-

Zip (postal code)

Company

Attn: First name
Phone

Email ||not for public release||
Street1
Street2
Street3
City

208.1 Email address where ITSP regulatory fee bill should be sent

)
)

State

Last
ext-

Fax

(

)

-

(

)

-

Country if not USA
MI

(

)

-

Zip (postal code)

Last
ext-

Fax

Country if not USA

||not for public release||

All carriers and providers of interconnected VoIP must complete Lines 209 through 213. During the year, carriers
and providers of interconnected VoIP must refile Blocks 1, 2, and 6 if there are any changes in this section. See Instructions.

209
210
211
212

D.C. Agent for Service of Process per 47 U.S.C. § 413
Telephone number of D.C. agent
Fax number of D.C. agent
Email of D.C. agent

Company

213

Complete business address of D.C. agent
for hand service of documents

Street1
Street2
Street3
City

214
215
216
217

Local/alternate Agent for Service of Process (optional)
Telephone number of local/alternate agent
Fax number of local/alternate agent
Email of local/alternate agent

Company

218

Complete business address of local/alternate
agent for hand service of documents

Street1
Street2
Street3
City

Attn First name

(
(

)
)

State

-

ext -

DC

Zip
Attn First name

(
(

)
)

State

-

MI

Last

MI

Last

ext -

Zip (postal code)

Country if not USA

PERSONS MAKING WILLFUL 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-A / March 2011

2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues)
Block 2-C: FCC Registration and Contact Information
219
220
221
222

Filer 499 ID [from Line 101]
Legal name of reporting entity [from Line 102]
Chief Executive Officer (or, highest ranking company officer
if the filing entity does not have a chief executive officer)
Business address of individual named on Line 221

Page 3

Filers must refile Blocks 1, 2 and 6
if there are any changes in this section. See Instructions.

First

MI

Last

Street1
Street2

check if same as Line 109
223
224

Street3
City

State

First
Second ranking company officer, such as Chairman
(Must be someone other than the individual listed on Line 221)
Street1
Business address of individual named on Line 223

Zip (postal code)
MI

Country if not USA
Last

Street2

check if same as Line 109
225

226

Street3
City

Third ranking company officer, such as President or Secretary
(Must be someone other than individuals listed on
Lines 221 and 223)
Business address of individual named on Line 225

State

First

Zip (postal code)
MI

Country if not USA
Last

Street1
Street2

check if same as Line 109
227

228

Street3
City

State

Zip (postal code)

Country if not USA

Indicate jurisdictions in which the filing entity provides service. Include jurisdictions in which service was provided in the past 15 months
and jurisdictions in which service is likely to be provided in the next 12 months
Alabama

Guam

Massachusetts

New York

Tennessee

Alaska

Hawaii

Michigan

North Carolina

Texas

American Samoa

Idaho

Midway Atoll

North Dakota

Utah

Arizona

Illinois

Minnesota

Northern Mariana Islands

U.S. Virgin Islands

Arkansas

Indiana

Mississippi

Ohio

Vermont

California

Iowa

Missouri

Oklahoma

Virginia

Colorado

Johnston Atoll

Montana

Oregon

Wake Island

Connecticut

Kansas

Nebraska

Pennsylvania

Washington

Delaware

Kentucky

Nevada

Puerto Rico

West Virginia

District of Columbia

Louisiana

New Hampshire

Rhode Island

Wisconsin

Florida

Maine

New Jersey

South Carolina

Wyoming

Georgia

Maryland

New Mexico

South Dakota

Year and month filer first provided (or expects to provide) telecommunications in the U.S

Check if prior to 1/1/1999, otherwise:

Year

Month

PERSONS MAKING WILLFUL 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-A / March 2011

2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues)

Page 4

Block 3: Carrier's Carrier Revenue Information
301
Filer 499 ID [from Line 101]
302
Legal name of reporting entity [from Line 102]
Report billed revenues for January 1 through December 31, 2010.
Do not report any negative numbers. Dollar amounts may be rounded to
the nearest thousand dollars. However, report all amounts as whole dollars.
See instructions regarding percent interstate and international
Revenues from Services Provided for Resale as Telecommunications
by Other Contributors to Federal Universal Service Support Mechanisms

Total
Revenues
(a)

If breakouts are not book
amounts, enter whole
percentage estimates
Interstate International
(b)
(c)

Breakouts
Interstate
Revenues
(d)

International
Revenues
(e)

Fixed local service
Monthly service, local calling, connection charges, vertical features,
and other local exchange service including subscriber line and
PICC charges to IXCs
303.1
Provided as unbundled network elements (UNEs)
303.2
Provided under other arrangements
Per-minute charges for originating or terminating calls
304.1
Provided under state or federal access tariff
304.2
Provided as unbundled network elements or other contract arrangement
Local private line & special access service
305.1
Provided to other contributors for resale as telecommunications
305.2
Provided to other contributors for resale as interconnected VoIP
306
Payphone compensation from toll carriers
307
Other local telecommunications service revenues
308
Universal service support revenues received from Federal or state sources
Mobile services (i.e., wireless telephony, paging, messaging, and other mobile services)
309
Monthly, activation, and message charges except toll
Toll services
310
Operator and toll calls with alternative billing arrangements (credit card,
collect, international call-back, etc.)
311
Ordinary long distance (direct-dialed MTS, customer toll-free (800/888
etc.) service, "10-10" calls, associated monthly account maintenance,
PICC pass-through, and other switched services not reported above)
312
Long distance private line services
313
Satellite services
314
All other long distance services
315

Total revenues from resale [Lines 303 through 314]
Note: As stated in the instructions, for all revenues reported on this page, you must retain the Filer 499 ID and contact information for the associated
customers. You must verify that each of these customers was a direct contributor to the federal universal service support mechanism for calendar year 2010
and that the customer is purchasing service for resale as telecommunications. These records must be made available to the administrator or
the FCC upon request. The FCC website contains information on federal universal service contributors. (See instructions.)

PERSONS MAKING WILLFUL 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-A / March 2011

2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues)

Page 5

Block 4-A: End-User and Non-Telecommunications Revenue Information
401
Filer 499 ID [from Line 101]
402
Legal name of reporting entity [from Line 102]
Report billed revenues for January 1 through December 31, 2010.
Do not report any negative numbers. Dollar amounts may be rounded to
the nearest thousand dollars. However, report all amounts as whole dollars.
See instructions regarding percent interstate and international
Revenues from All Other Sources (end-user telecom. & non-telecom.)
403
Surcharges or other amounts on bills identified as recovering
State or Federal universal service contributions

Total
Revenues
(a)

If breakouts are not book
amounts, enter whole
percentage estimates
Interstate International
(b)
(c)

Breakouts
Interstate
Revenues
(d)

International
Revenues
(e)

Fixed local services
Monthly service, local calling, connection charges, vertical features,
and other local exchange service charges except for federally
tariffed subscriber line charges and PICC charges
Traditional Circuit Switched
404.1
Provided at a flat rate including interstate toll service -- local portion
404.2
Provided at a flat rate including interstate toll service -- toll portion
404.3
Provided without interstate toll included (see instructions)
Interconnected VoIP
404.4
Offered in conjunction with a broadband connection
404.5
Offered independent of a broadband connection
405
Tariffed subscriber line charges and PICC charges levied by a local
exchange carrier on a no-PIC customer
406
Local private line & special access service [Includes the transmission
portion of wireline broadband Internet access provided on a common
carrier basis.]
407
Payphone coin revenues (local and long distance)
408
Other local telecommunications service revenues
Mobile services (i.e., wireless telephony, paging, messaging, and other mobile services)
409
Monthly and activation charges
410
Message charges including roaming and air-time charges for toll
calls, but excluding separately stated toll charges
PERSONS MAKING WILLFUL 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-A / March 2011

2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues)

Page 6

Block 4-A: Continued

Total
Revenues
(a)
Toll services
411
Prepaid calling card (including card sales to customers
and non-carrier distributors) reported at face value of cards
412
International calls that both originate and terminate in foreign points
413
Operator and toll calls with alternative billing arrangements (credit
card, collect, international call-back, etc.) other than revenues
reported on Line 412
Ordinary long distance (direct-dialed MTS, customer toll-free (800/888
etc.) service , "10-10" calls, associated monthly account maintenance,
PICC pass-through, and other switched services not reported above)
414.1
All, other than interconnected VoIP, including, but not limited to,
itemized toll on wireline and wireless bills
414.2
All interconnected VoIP long distance, including, but not limited to,
itemized toll
415
Long distance private line services
416
Satellite services
417
All other long distance services

If breakouts are not book
amounts, enter whole
percentage estimates
Interstate International
(b)
(c)

0%

Breakouts
Interstate
Revenues
(d)

International
Revenues
(e)

100%

Revenues other than U.S. telecommunications revenues, including information services,
inside wiring maintenance, billing and collection customer premises equipment, published
directory, dark fiber, Internet access, cable TV program transmission, foreign carrier
operations, and non-telecommunications revenues (See instructions.)

418.1
418.2
418.3

bundled with circuit switched local exchange service
bundled with interconnected VoIP local exchange service
other

Block 4-B: Total Revenue and Uncollectible Revenue Information
419
420
421
422
423

Gross billed revenues from all sources (incl. reseller & non-telecom.)
[Lines 303 through 314 plus Lines 403 through 418]
Gross universal service contribution base amounts [Lines 403 through 411 plus
Lines 413 through 417] [See Table 3 in instructions.]
Uncollectible revenue/bad debt expense associated with gross
billed revenues amounts shown on Line 419 [See instructions.]
Uncollectible revenue/bad debt expense associated with universal
service contribution base amounts shown on Line 420
Net universal service contribution base revenues
[Line 420 minus line 422]

PERSONS MAKING WILLFUL 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-A / March 2011

2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues)

Page 7

Block 5: Additional Revenue Breakouts
501
Filer 499 ID [from Line 101]
502
Legal name of reporting entity [from Line 102]
Filers that report revenues in Block 3 and Block 4 must provide the percentages requested in Lines 503 through 510.
See instructions for limited exceptions.
Percentage of revenues reported in Block 3 and Block 4 billed in each region of the country. Round or
estimate to nearest whole percentage. Enter 0 if no service was provided in the region.
503
504
505
506
507
508
509
510
511

Southeast:

Block 3
Carrier's
Carrier
(a)

Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina,
Puerto Rico, South Carolina, Tennessee, and U.S. Virgin Islands
Western:
Alaska, Arizona, Colorado, Idaho, Iowa, Minnesota, Montana, Nebraska, New Mexico,
North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming
West Coast:
California, Hawaii, Nevada, American Samoa, Guam, Johnston Atoll, Midway Atoll,
Northern Mariana Islands, and Wake Island.
Mid-Atlantic: Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania, Virginia, and
West Virginia
Mid-West:
Illinois, Indiana, Michigan, Ohio, and Wisconsin
Northeast:
Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont
Southwest:
Arkansas, Kansas, Missouri, Oklahoma, and Texas
Total:
[Percentages must add to 0 or 100.]
Revenues from resellers that do not contribute to universal service support mechanisms are included in Block 4-B, Line 420 but may be excluded from a
filer's TRS, NANPA, LNP, and FCC interstate telephone service provider regulatory fee contribution bases. To have these amounts excluded, the filer has the
option of identifying such revenues below. As stated in the instructions, you must have in your records the FCC Filer 499 ID for each customer
whose revenues are included on Line 511. (See instructions.)
(a)
Total Revenues
Revenues from resellers that do not contribute to Universal Service
$
$

Block 4
End-User
Telecom.
(b)
%

%

%

%

%

%

%

%

%
%
%
%

%
%
%
%

(b)
Interstate and International

PERSONS MAKING WILLFUL 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-A / March 2011

2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues)

Page 8

Block 6: CERTIFICATION: to be signed by an officer of the filer
601
602

Filer 499 ID [from Line 101]
Legal name of reporting entity [from Line 102]
Section IV of the instructions provides information on which types of reporting entities are required to file for which purposes. Any entity claiming
to be exempt from one or more contribution requirements should so certify below and attach an explanation. [The Universal Service Administrator
will determine which entities meet thede minimis threshold based on information provided in Block 4, even if you fail to so certify below.]

603

I certify that the reporting entity is exempt from contributing to

Universal Service

TRS

NANPA

LNP Administration

Provide explanation below:

State or Local Government Entity

I.R.C. § 501 or State Tax Exempt (see instructions)

604

Please indicate whether the reporting entity is

605

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 as defined in the instructions, 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 and that said Worksheet is an accurate
statement of the affairs of the above-named company for the previous calendar year. In addition, I swear, under penalty of perjury, that all
requested identification registration information has been provided and is accurate. If the above-named reporting entity is filing on a
consolidated basis, I certify that this filing incorporates all of the revenues for the consolidated entities for the entire year and that
the filer adhered to and continues to meet the conditions set forth in section II-C of the instructions.

606

Signature

607

Printed name of officer

608

Position with reporting entity

609

Business telephone number of officer

610

Email of officer || not for public release ||

611

Date

612

Check those that apply:

First

Original April 1 filing for year

MI

(

New filer, registration only

)

Last

-

ext -

Revised filing with updated registration

Revised filing with updated revenue data

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 information: (888) 641-8722 or via email: [email protected]
PERSONS MAKING WILLFUL 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-A / March 2011