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

Telecommunications Reporting Worksheets and Related Collections, FCC Forms 499-A and 499-Q

2017 FCC Form 499-A

Telecommunications Reporting Worksheets and Related Collections, FCC Forms 499-A and 499-Q

OMB: 3060-0855

Document [docx]
Download: docx | pdf

2017 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2016 Revenues) APPROVED BY OMB

3060-0855

>>> Please read instructions before completing.<<<


Annual Filing -- due April 1, 2017


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

[Enter 9 digit 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.]


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)


Toll Reseller

Wireless Data

Other Local

Other Mobile

Other Toll


If Other Local, Other Mobile or Other Toll is checked

describe carrier type / services provided:



106.1

Affiliated Filers Name/Holding Company Name (All affiliated companies must show the same name on this line.)


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

Street1

Street2

Street3

City State Zip (postal code) Country

110

Complete business address for customer inquiries and complaints


check if same address as Line 109

Street1

Street2

Street3

City State Zip (postal code) Country

111

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

( ) - ext -

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


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


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


2017 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2016 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

Contact person name, office name, and mailing address of a corporate office to which correspondence regarding this Telecommunications Reporting Worksheet 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

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

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

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


2017 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2016 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

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

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

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


2017 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2016 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, 2016.

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













303.1

Monthly service, local calling, connection charges, vertical features,

and other local exchange service including subscriber line and

PICC charges to IXCs

Provided as unbundled network elements (UNEs)











303.2

Provided under other arrangements







304.1

Per-minute charges for originating or terminating calls

Provided under state or federal access tariff






304.2

Provided as unbundled network elements or other contract arrangement







Local private line & business data 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


2017 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2016 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, 2016.

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 & business data 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


2017 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2016 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


2017 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2016 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


2017 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2016 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 III-B 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. File this form online: http://www.usac.org/about/tools/e-file.aspx

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

I

Save time, avoid problems – file electronically at

http://forms.universalservice.org

FCC Form 499-A / XXXX 2017


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2010 Revenues)
AuthorVickie Robinson
File Modified0000-00-00
File Created2021-01-23

© 2024 OMB.report | Privacy Policy