FCC Form 499-Q Telecommunications Reporting Worksheet - Quarterly Filin

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