2016 FCC Form 499-A

Attachment 1
20156 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 20154 Revenues)

APPROVED BY

OMB
3060-0855
>>> Please read instructions before completing.<<<
Annual Filing -- due April 1, 20165

Block 1: Contributor Identification Information

102

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

103
104
105

IRS employer identification number
[Enter 9 digit number]
Name filer is doing business as
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.]

101

 Audio Bridging (teleconferencing) Provider
 Coaxial Cable
 Incumbent LEC
 Non-Interconnected VoIP
 Operator Service Provider
 Private Service Provider
 Satellite Service Provider
 Toll Reseller
 Wireless Data
106.1
106.2
107

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.)

108
109

Affiliated Filers Name/Holding Company Name IRS employer identification number
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]]
Management company [if filer is managed by another entity]
Complete mailing address of reporting entity corporate headquarters

110

Complete business address for customer inquiries and complaints
check if same address as Line 109

111
112

 CAP/CLEC
 Cellular/PCS/SMR (wireless telephony inc. by resale)
 Interconnected VoIP
 Interexchange Carrier (IXC)
 Local Reseller
 Paging & Messaging
 Payphone Service Provider
 Prepaid Card
 Shared-Tenant Service Provider / Building LEC
 SMR (dispatch)
 Other Local
 Other Mobile
 Other Toll

Check if filer has no affiliates



[Enter 9 digit number]
[Enter 10 digit number]



Street1
Street2
Street3
City
Street1
Street2
Street3
City

State

Zip (postal code)

State
Zip (postal code)
Telephone number for customer complaints and inquiries [Toll-free number if available]
( )
ext 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

Country

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 / XXXX 20154

Attachment 1
20165 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 20154 Revenues)

Page 2

Block 2-A: Regulatory Contact Information
201
202
203
204
205
206
207

Filer 499 ID [from Line 101]
Legal name of filer [from Line 102]
Person who completed this Worksheet
Telephone number of this person
Fax number of this person
Email of this person not for public release
Contact person name, office namerporate office, attn. name, and
mailing address of a corporate office to to which correspondence
regarding thisfuture Telecommunications Reporting Worksheets
should be sent.


check if same address as Line 109 
check if same name as Line 203

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
209
210
211
212
213

D.C. Agent for Service of Process
Telephone number of D.C. agent
Fax number of D.C. agent
Email of D.C. agent
Complete business address of D.C. agent
for hand service of documents

214
215
216
217
218

Local/alternate Agent for Service of Process (optional)
Telephone number of local/alternate agent
Fax number of local/alternate agent
Email of local/alternate agent
Complete business address of local/alternate agent
for hand service of documents



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
Company
Attn: First name
MI
Last
(
)
ext (
)
Street1
Street2
Street3
City
Company

State
(
(

)
)

DC
-

Zip
Attn: First name
ext -

MI

Last

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 / XXXX 20154

Attachment 1
20156 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 20145 Revenues)
Block 2-C: FCC Registration and Contact Information
219
220
221
222

Filer 499 ID [from Line 101]
Legal name of filer [from Line 102]
Chief Executive Officer (or, highest ranking company officer if
the filer does not have a chief executive officer)
Business address of individual named on Line 221
check if same as Line 109

223
224

225

226

228



Street1
Street2
Street3
City
First



Street1
Street2
Street3
City
First

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

MI

Last

State

Zip (postal code)
MI
Last

Country

State

Zip (postal code)
MI
Last

Country

Street1
Street2
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.
check if same as Line 109

227

First

Second ranking company officer, such as Chairman
(Must be someone other than the individual listed on Line 221)
Business address of individual named on Line 223
check if same as Line 109

Page 3

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



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

Check if prior to 1/1/1999, otherwise:
Year and month filer first provided (or expects to provide) telecommunications in the U.S.
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 / XXXX 20154

Attachment 1
20156 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 20154 Revenues)

Page 4

Block 3: Carrier’s Carrier Revenue Information
Filer 499 ID [from Line 101]
301
Legal name of filer [from Line 102]
302
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

International
Revenues

(d)

(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
Provided as unbundled network elements (UNEs)
Provided under other arrangements
303.2
Per-minute charges for originating or terminating calls
Provided under state or federal access tariff
304.1
Provided as unbundled network elements or other contract arrangement
304.2
Local private line & special access service
Provided to other contributors for resale as telecommunications
305.1
Provided to other contributors for resale as interconnected VoIP
305.2
Payphone compensation from toll carriers
306
Other local telecommunications service revenues
307
Universal service support revenues received from Federal or state sources
308
Mobile services (i.e., wireless telephony, paging, messaging, and other mobile services)
Monthly, activation, and message charges except toll
309
Toll services
Operator and toll calls with alternative billing arrangements (credit card, collect,
310
international call-back, etc.)
Ordinary long distance(direct-dialed MTS, customer toll-free (800/888
311
etc.) service, “10-10” calls, associated monthly account maintenance,
PICC pass-through, and other switched services not reported above)
Long distance private line services
312
Satellite services
313
All other long distance services
314
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 / XXXX 20154

Attachment 1
20165 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 20154 Revenues)

Page 5

Block 4-A: End-User and Non-Telecommunications Revenue Information
Filer 499 ID [from Line 101]
401
Legal name of filer [from Line 102]
402
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.

Total
Revenues

See instructions regarding percent interstate and international.

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

Breakouts
Interstate
Revenues

International
Revenues

(d)

(e)

(a)
Revenues from All Other Sources (end-user, telecom. & non-telecom.)
Surcharges or other amounts on bills identified as recovering
403
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
Provided at a flat rate including interstate toll service – local portion
404.1
Provided at a flat rate including interstate toll service – toll portion
404.2
Provided without interstate toll included (see instructions)
404.3
Interconnected VoIP
Offered in conjunction with a broadband connection
404.4
Offered independent of a broadband connection
404.5
Tariffed subscriber line charges, Access Recovery Charges, and PICC charges
405
levied by a local exchange carrier on a no-PIC customer
Local private line & special access service [Includes the transmission
406
portion of wireline broadband Internet access provided on a common
carrier basis.]
Payphone coin revenues (local and long distance)
407
Other local telecommunications service revenues
408
Mobile services (i.e., wireless telephony, paging, messaging, and other mobile services)
Monthly and activation charges
409
Message charges including roaming and air-time charges for toll
410
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 / XXXX 20154

Attachment 1
20156 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 20145 Revenues)

Page 6

Block 4-A: Continued
Total
Revenues

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

Breakouts
Interstate
Revenues

International
Revenues

(d)

(e)

(a)
Toll services
Prepaid calling card (including card sales to customers)
411
and non-carrier distributors) reported at face value of cards
International calls that both originate and terminate in foreign points
412
Operator and toll calls with alternative billing arrangements (credit
413
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,
414.1
itemized toll on wireline and wireless bills
All interconnected VoIP long distance, including, but not limited to,
414.2
itemized toll
Long distance private line services
415
Satellite services
416
All other long distance services
417
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
418.1
bundled with interconnected VoIP local exchange service
418.2
Other
418.3
418.4

0%

100%

non-interconnected VoIP revenues not included in any other category

Block 4-B: Total Revenue and Uncollectible Revenue Information
419
420
421
422
423

Gross billed revenues from all sources (incl. reseller & non-telecom.)
[Lines 303 through 314 plus Lines 403 through 418]
Gross universal service contribution base amounts [Lines 403 through 411 plus
Lines 413 through 417] [See Table 3 in instructions.]
Uncollectible revenue/bad debt expense associated with gross
billed revenues amounts shown on Line 419 [See instructions.]
Uncollectible revenue/bad debt expense associated with universal
service contribution base amounts shown on Line 420
Net universal service contribution base revenues
[Line 420 minus line 422]

Save time, avoid problems – file electronically at

http://forms.universalservice.org

FCC Form 499-A / XXXX 20145

Attachment 1
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 / XXXX 20145

Attachment 1
20156 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 20145 Revenues)

Page 7

Block 5: Additional Revenue Breakouts
Filer 499 ID [from Line 101]
501
Legal name of filer [from Line 102]
502
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)

507
508
509

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
Mid-West:
Illinois, Indiana, Michigan, Ohio, and Wisconsin
Northeast:
Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont
Southwest:
Arkansas, Kansas, Missouri, Oklahoma, and Texas

510

Total:

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.)

503
504
505
506

Southeast:

[Percentages must add to 0 or 100.]

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 / XXXX 20145

Attachment 1
20156 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 20145 Revenues)

Page 8

Block 6: CERTIFICATION: to be signed by an officer of the filer
601
602

Filer 499 ID [from Line 101]
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

Universal Service

I certify that the filer is exempt from contributing to:

TRS

NANPA

LNP Administration

Provide explanation below:
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
604

Please indicate whether the filer is

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.

State or Local Government Entity

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

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
608
609
610
611
612

Printed name of officer
Position with reporting entity
Business telephone number of officer
Email of officer not for public release
Date
Check those that apply
Original April 1 filing for year

______________________________________________________________________________
First

MI
(

)

New filer, registration only

-

Last
ext -

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 / XXXX 20145