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2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2010 Revenues) APPROVED BY OMB
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | 2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2010 Revenues) APPROVED BY OMB |
| Author | Vickie Robinson |
| Last Modified By | Writer |
| File Modified | 2013-12-31 |
| File Created | 2026-07-16 |
| Conversion State | complete |
Extracted Text
2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 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
2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 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
2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 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, 2013.
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
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]
See section III.C.2 of the instructions for the requirements applicable to revenue reported on this page. 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
2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 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, 2013.
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
Save time, avoid problems – file electronically at
http://forms.universalservice.org
FCC Form 499-A / January 2014
2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 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
2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 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
Save time, avoid problems – file electronically at
http://forms.universalservice.org
FCC Form 499-A / January 2014
2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 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 / January 2014