FCC Form 499-A Telecommunications Reporting Worksheet - FCC Form 499-A

2015 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2014 Revenues)

APPROVED BY OMB

>>> Please read instructions before completing<<<

3060-0855

Annual Filing -- due April 1, 2015

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

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.]

[Enter 9 digit number]

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)

106.1

Toll Reseller
Wireless Data
Other Local
If Other Local, Other Mobile or Other Toll is checked

describe carrier type / services provided:
Affiliated Filers Name/Holding Company Name (All affiliated companies must show the same name on this line.)

Other Mobile

Check if filer has no affiliates

106.2

Affiliated Filers Name/Holding Company Name 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

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

State

Zip (postal code)

Country

111

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

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
b
c
d
e
f

Other Toll

(

)

-

ext -

g
h
i
j
k
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

Save time, avoid problems – file electronically at

http://forms.universalservice.org

FCC Form 499-A / December 2014

2015 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2014 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

204

Telephone number of this person

(

)

-

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

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

208.1

Email address pertaining to ITSP regulatory fee issues

Block 2-B: Agent for Service of Process

First

MI

Last
ext -

Office
Attn: First name
MI
Last
Email not for public release
Phone (
)
extFax (
)
- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - Street1
Street2
Street3
City
State
Zip (postal code)
Country
Company
Attn: First name
MI
Last
Email not for public release
Phone (
)
extFax (
)
- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - Street1
Street2
Street3
City
State
Zip (postal code)
Country
not for public release
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

210

Telephone number of D.C. agent

(

)

-

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

214

Local/alternate Agent for Service of Process (optional)

Company

215

Telephone number of local/alternate agent

(

)

-

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

Company

Attn: First name

State

MI

Last

MI

Last

ext -

DC

Zip
Attn: First name
ext -

Street1
Street2
City
State
Zip (postal code)
Country
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 / December 2014

2015 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2014 Revenues)
Block 2-C: FCC Registration and Contact Information
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

222

Business address of individual named on Line 221

Street1
Street2
Street3
City
First

check if same as Line 109
223

Second ranking company officer, such as Chairman
(Must be someone other than the individual listed on Line 221)

224

Business address of individual named on Line 223
check if same as Line 109

225

226

227

228

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

Page 3

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

MI

Street1
Street2
Street3
City
First

Last

State

Zip (postal code)
MI
Last

Country

State

Zip (postal code)
MI
Last

Country

Street1
Street2
check if same as Line 109
Street3
City
State
Zip (postal code)
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.

Country

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 / December 2014

2015 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2014 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, 2014.
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
Interstate
International
(b)
(c)

Breakouts
Interstate
Revenues
(d)

International
Revenues
(e)

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
303.2

Provided as unbundled network elements (UNEs)
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

Save time, avoid problems – file electronically at

http://forms.universalservice.org

FCC Form 499-A / December 2014

2015 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2014 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, 2014.
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
404.3

Provided at a flat rate including interstate toll service – toll portion
Provided without interstate toll included (see instructions)
Interconnected VoIP

404.4
404.5
405

Offered in conjunction with a broadband connection
Offered independent of a broadband connection

406

Tariffed subscriber line charges, Access Recovery Charges, and PICC charges
levied by a local exchange carrier on a no-PIC customer
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 / December 2014

2015 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2014 Revenues)

Page 6

Block 4-A: Continued

Total
Revenues
(a)

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

Breakouts
Interstate
Revenues
(d)

International
Revenues
(e)

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)
All, other than interconnected VoIP, including, but not limited to,
itemized toll on wireline and wireless bills
All interconnected VoIP long distance, including, but not limited to,
itemized toll

414.1
414.2
415

Long distance private line services

416

Satellite services

417

All other long distance services

418.1
418.2

0%

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)
bundled with circuit switched local exchange service
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

Save time, avoid problems – file electronically at

http://forms.universalservice.org

FCC Form 499-A / December 2014

2015 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2014 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.
503

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

%

%

%

%

%

%

%

%

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.)

504
505
506

Southeast:

Block 4
End-User Telecom
(b)

(a)

(b)

Total Revenues

Interstate and International

Revenues from resellers that do not contribute to Universal Service
512
513
514

Gross TRS contribution base amounts
[Lines 403 through 417 plus Line 418.4 less Line 511]
Uncollectible revenue/bad debt expense associated with TRS contribution base amounts
shown on Line 512
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 / December 2014

2015 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2014 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:

604

Please indicate whether the filer is

Universal Service
TRS
NANPA
LNP Administration
Provide explanation below:
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________

605

I.R.C. § 501 or State Tax Exempt (see instructions)
State or Local Government Entity
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 IIC 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

MI

(

)

-

Last

ext -

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 / December 2014