FCC Form 499-Q Telecommunications Reporting Worksheet - Quarterly Filin

Telecommunications Reporting Worksheets and Related Collections, FCC Forms 499-A and 499-Q

0855_FCCForm 499Q_090413(clean)

FCC Forms 499-A and 499-Q, Telecommunications Reporting Worksheets

OMB: 3060-0855

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PN ATTACHMENT 3 DRAFT FCC FORM 499-Q / PAGE 1

FCC Form 499-Q Telecommunications Reporting Worksheet Approval by OMB

Quarterly Filing for Universal Service Contributors > Please read instructions before completing < 3060-0855

Block 1: Contributor Identification Information

101 Filer 499 ID


102 Legal name of reporting entity


103 Filer’s IRS employer identification number


104 Name telecommunications provider is doing business as


105 Holding company

[All affiliated companies should show same name here.]

Check if filer has no affiliates:

105.1 Holding company IRS employer identification number

[Enter 9 digit number]

106 Filer’s FCC Registration Number (FRN)

[Enter 10 digit number]

107 Complete mailing address of reporting entity's corporate headquarters


Block 2: Contact Information

108 Person who completed this worksheet

First MI Last

109 Telephone number of this person

( ) -

110 Fax number of this person

( ) -

111 Email of this person


112 Billing address and billing contact person:

[Bills for Universal Service contributions

will be sent to this address.]


Block 3: Contributor Historical and Projected Revenue Information

113 Indicate which

quarterly filing

this represents


Filing due

November 1, 2013

February 1, 2014

May 1, 2014

August 1, 2014

Historical revenues (lines 115-118) for

July 1 – September 30, 2013

October 1 – December 31, 2013

January 1 – March 31, 2014

April 1 – June 30, 2014

Projected revenues (lines 119-120) for

January 1 – March 31, 2014

April 1 – June 30, 2014

July 1 – September 30, 2014

October 1 – December 31, 2014

114

Check if using safe harbor to allocate interstate/intrastate revenues for each of the following (as applicable):

Cellular & broadband PCS: Paging: Analog SMR: Interconnected VoIP:

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

Total Revenues

(a)

Interstate Revenues

(b)

International Revenues

(c)

115

Telecommunications provided to other universal service contributors for resale as telecommunications or as interconnected VoIP




116

End-user telecommunications revenues including any pass-through charges for universal service contributions, but excluding international-to-international revenues




117

All other goods and services


Column (b) and (c) not requested

for Lines 117 and 118

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



120

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



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

First MI Last

124 Position with reporting entity


125 Email of officer (Required if available)


126 Date


127 This filing is:

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 email: Form [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 September 2013



File Typeapplication/msword
File TitleFCC Form 499-Q Telecommunications Reporting Worksheet
AuthorErnesto Beckford
Last Modified Byjudith
File Modified2013-09-04
File Created2013-09-04

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