Form FCC Form 499-A FCC Form 499-A 2013 Telecommunications Reporting Worksheet (Reporting 2

PN ATTACHMENT 1 DRAFT FCC FORM 499-A / PAGE 1

2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 Revenues) APPROVED BY OMB

3060-0855

>>> Please read instructions before completing.<<<

Annual Filing -- due April 1, 2013

Block 1: Contributor Identification Information

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

101

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 filer

103

IRS employer identification number

[Enter 9 digit number]

104

Name filer 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.]

 Audio Bridging (teleconferencing) Provider

 CAP/CLEC

 Cellular/PCS/SMR (wireless telephony inc. by resale)

 Coaxial Cable

 Incumbent LEC

 Interconnected VoIP

 Interexchange Carrier (IXC)

 Local Reseller

 Non-Interconnected VoIP

 Operator Service Provider

 Paging & Messaging

 Payphone Service Provider

 Prepaid Card

 Private Service Provider

 Satellite Service Provider

 Shared-Tenant Service Provider / Building LEC

 SMR (dispatch)

 Toll Reseller

 Wireless Data

 Other Local

 Other Mobile

 Other Toll

If Other Local, Other Mobile or Other Toll is checked

describe carrier type / services provided:



106.1

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

Check if filer has no affiliates 

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

Management company [if filer is managed by another entity]

109

Complete mailing address of reporting entity corporate headquarters

Street1

Street2

Street3

City State Zip (postal code) Country if not USA

110

Complete business address for customer inquiries and complaints

check if same address as Line 109 

Street1

Street2

Street3

City 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 additional sheets if necessary. Each filer 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

2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 Revenues) Page 2
Block 2-A: Regulatory Contact Information
201	Filer 499 ID [from Line 101]
202	Legal name of filer [from Line 102]
203	Person who completed this Worksheet	First MI Last
204	Telephone number of this person	( ) - ext -
205	Fax number of this person	( ) -
206	Email of this person not for public release
207	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 	Office Attn: First name MI Last Email not for public release Phone ( ) - ext- Fax ( ) - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - Street1 Street2 Street3 City State Zip (postal code) Country if not USA
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 	Company Attn: First name MI Last Email not for public release Phone ( ) - ext- Fax ( ) - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - Street1 Street2 Street3 City State Zip (postal code) Country if not USA
208.1	Email address pertaining to ITSP regulatory fee issues	not for public release
Block 2-B: Agent for Service of Process		All carriers and providers of interconnected and non-interconnected VoIP must complete Lines 209 through 213. During the year, these filers must refile Blocks 1, 2, and 6 if there are any changes in this section. See Instructions
209	D.C. Agent for Service of Process	Company Attn: First name MI Last
210	Telephone number of D.C. agent	( ) - ext -
211	Fax number of D.C. agent	( ) -
212	Email of D.C. agent
213	Complete business address of D.C. agent for hand service of documents	Street1 Street2 Street3 City State DC Zip
214	Local/alternate Agent for Service of Process (optional)	Company Attn: First name MI Last
215	Telephone number of local/alternate agent	( ) - ext -
216	Fax number of local/alternate agent	( ) -
217	Email of local/alternate agent
218	Complete business address of local/alternate agent for hand service of documents	Street1 Street2 City State 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

2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 Revenues) Page 3
Block 2-C: FCC Registration and Contact Information			Filers must refile Blocks 1, 2 and 6 if there are any changes in this section. See Instructions.
219	Filer 499 ID [from Line 101]
220	Legal name of filer [from Line 102]
221	Chief Executive Officer (or, highest ranking company officer if the filer does not have a chief executive officer)			First MI Last
222	Business address of individual named on Line 221 check if same as Line 109 			Street1 Street2 Street3 City State Zip (postal code) Country if not USA
223	Second ranking company officer, such as Chairman (Must be someone other than the individual listed on Line 221)			First MI Last
224	Business address of individual named on Line 223 check if same as Line 109 			Street1 Street2 Street3 City State Zip (postal code) Country if not USA
225	Third ranking company officer, such as President or Secretary (Must be someone other than individuals listed on Lines 221 and 223)			First MI Last
226	Business address of individual named on Line 225 check if same as Line 109 			Street1 Street2 Street3 City State Zip (postal code) Country if not USA
227	Indicate jurisdictions in which the filer 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
228	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

2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 Revenues) Page 4
Block 3: Carrier’s Carrier Revenue Information
301	Filer 499 ID [from Line 101]
302	Legal name of filer [from Line 102]
Report billed revenues for January 1 through December 31, 2012. 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.		Total Revenues (a)	If breakouts are not book amounts, enter whole percentage estimates		Breakouts
					Interstate Revenues (d)	International Revenues (e)
			Interstate (b)	International (c)
Revenues from Services Provided for Resale as Telecommunications by Other Contributors to Federal Universal Service Support Mechanisms Fixed local service
303.1	Monthly service, local calling, connection charges, vertical features, and other local exchange service including subscriber line and PICC charges to IXCs Provided as unbundled network elements (UNEs)
303.2	Provided under other arrangements
304.1	Per-minute charges for originating or terminating calls 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]
Except as noted in the Instructions, for all revenues reported on this page, you must: (1) retain the Filer 499 ID and contact information for the associated customers, (2) verify that each of these customers was a “reseller “for calendar year 2012, and (3) verify that the customer is purchasing service for resale as telecommunications. These records must be made available to the administrator or the FCC upon request.
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

2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 Revenues) Page 5
Block 4-A: End-User and Non-Telecommunications Revenue Information
401	Filer 499 ID [from Line 101]
402	Legal name of filer [from Line 102]
Report billed revenues for January 1 through December 31, 2012. 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.		Total Revenues (a)	If breakouts are not book amounts, enter whole percentage estimates		Breakouts
					Interstate Revenues (d)	International Revenues (e)
			Interstate (b)	International (c)
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
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, Access Recovery 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

2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 Revenues) Page 6
Block 4-A: Continued
		Total Revenues (a)	If breakouts are not book amounts, enter whole percentage estimates		Breakouts
					Interstate Revenues (d)	International Revenues (e)
			Interstate (b)	International (c)
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		0%	100%
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
	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	bundled with circuit switched local exchange service
418.2	bundled with interconnected VoIP local exchange service
418.3	Other
418.4	non-interconnected VoIP revenues not included in any other category
Block 4-B: Total Revenue and Uncollectible Revenue Information
419	Gross billed revenues from all sources (incl. reseller & non-telecom.) [Lines 303 through 314 plus Lines 403 through 418]
420	Gross universal service contribution base amounts [Lines 403 through 411 plus Lines 413 through 417] [See Table 3 in instructions.]
421	Uncollectible revenue/bad debt expense associated with gross billed revenues amounts shown on Line 419 [See instructions.]
422	Uncollectible revenue/bad debt expense associated with universal service contribution base amounts shown on Line 420
423	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

2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 Revenues) Page 7
Block 5: Additional Revenue Breakouts
501	Filer 499 ID [from Line 101]
502	Legal name of filer [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.
				Block 3 Carrier’s Carrier (a)	Block 4 End-User Telecom (b)
503	Southeast: Alabama, Florida, Georgia, Kentucky Louisiana, Mississippi, North Carolina, Puerto Rico, South Carolina, Tennessee, and U.S. Virgin Islands			%	%
504	Western: Alaska, Arizona, Colorado, Idaho, Iowa, Minnesota, Montana, Nebraska, New Mexico, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming			%	%
505	West Coast: California, Hawaii, Nevada, American Samoa, Guam, Johnston Atoll, Midway Atoll, Northern Mariana Islands, and Wake Island			%	%
506	Mid-Atlantic: Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania, Virginia, and, West Virginia			%	%
507	Mid-West: Illinois, Indiana, Michigan, Ohio, and Wisconsin			%	%
508	Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont			%	%
509	Southwest: Arkansas, Kansas, Missouri, Oklahoma, and Texas			%	%
510	Total: [Percentages must add to 0 or 100.]			%	%
511	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)	(b)
		Total Revenues	Interstate and International
Revenues from resellers that do not contribute to Universal Service
512	Gross TRS contribution base amounts [Lines 403 through 417 plus Line 418.4 less Line 511]
513	Uncollectible revenue/bad debt expense associated with TRS contribution base amounts shown on Line 512
514	Net TRS contribution base revenues [Line 512 less Line 513]
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

2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 Revenues) Page 8

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

601

Filer 499 ID [from Line 101]

602

Legal name of filer [from Line 102]

Section IV of the instructions provides information on which types of filers are required to file for which purposes. Any filer 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 filers meet the de minimis threshold based on information provided in Block 4, even if you fail to so certify below.]

603

I certify that the filer is exempt from contributing to:

Universal Service 

TRS 

NANPA 

LNP Administration 

Provide explanation below: ________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________

604

Please indicate whether the filer is

State or Local Government Entity 

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

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 filer 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 filer 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

First MI Last

608

Position with reporting entity

609

Business telephone number of officer

( ) - ext -

610

Email of officer not for public release

611

Date

612

Check those that apply

 Original April 1 filing for year

 New filer, registration only

 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 / XXX 2013 [[DRAFT]]