2016 FCC Form 499-Q

Attachment 3
FCC Form 499-Q Telecommunications Reporting Worksheet
Quarterly Filing for Universal Service Contributors > Please read instructions before completing <
101

Block 1: Contributor Identification Information
102 Legal name of reporting entity
103 Filer’s IRS employer identification number
104 Name telecommunications provider is doing business as
105 Affiliated Filers Name
[All affiliated companies should show same name here. In most cases, the
Affiliated Filers Name will be the holding company name
105.1 Affiliate Filers Name IRS employer identification number
106 Filer’s FCC Registration Number (FRN)
107 Complete mailing address of reporting entity's corporate headquarters

Approval by OMB
3060-0855

Filer 499 ID

Check if filer has no affiliates:



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

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
Filing due
Historical revenues (lines 115-118) for
Projected revenues (lines 119-120) for
quarterly filing
July 1 – September 30, 20145
January 1 – March 31, 20156
 November 1,
this represents
20154
October 1 – December 31, 20145
April 1 – June 30, 20156
 February 1, 20165
January 1 – March 31, 20156
July 1 – September 30, 20156
 May 1, 20156
April 1 – June 30, 20156
October 1 – December 31, 20156
 August 1, 20156
Check if using safe harbor to allocate interstate/intrastate revenues for each of the following (as applicable):
114
Cellular & broadband PCS: 

Paging:



Analog SMR:



Interconnected VoIP: 
Interstate Revenues
(b)

Total Revenues
Historical billed revenues with no allowance or deductions for
(a)
uncollectibles. See Instructions.
Telecommunications provided to other universal service
115
contributors for resale as telecommunications or as
interconnected VoIP
End-user telecommunications revenues including any pass116
through charges for universal service contributions, but
excluding international-to-international revenues
All other goods and services
117
Gross-billed revenues from all sources [sum of above]
118
Projected gross-billed end-user interstate and international telecommunications revenues
119
including any pass-through charges for universal service contributions, but excluding
international-to-international revenues
Projected collected end-user interstate and international telecommunications revenues
120
including any pass-through charges for universal service contributions, but excluding
international-to-international revenues

International Revenues
(c)

Column (b) and (c) not requested
for Lines 117 and 118

Block 4: CERTIFICATION: to be signed by an officer of the reporting entity
I certify that the revenue data contained herein are privileged and confidential and that public disclosure of such information
121

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
123
124
125
126
127

Signature
Printed name of officer
Position with reporting entity
Email of officer (Required if available)
Date
This filing is:

First

MI

 Original filing

Last

 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 /XXXX 20154

Attachment 3