Telecommunications Reporting Worksheet - Quarterly Filing for Universal Service Contributors

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html

FCC Form 499-Q Telecommunications Reporting Worksheet                                                                                                  Not Approval by OMB
Quarterly Filing for Universal Service Contributors  > Please read instructions before completing <                                            3060-0855
Block 1:  Contributor Identification Information
101     Filer 499 ID

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.]
Check if filer has no affiliates:   
105.1  Affiliate Filers Name IRS employer identification number
[Enter 9 digit number]
106  Filer’s FCC Registration Number (FRN)
[Enter 10 digit number]
107  Complete mailing address of reporting entity's corporate headquarters


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:
        

Block 3:  Contributor Historical and Projected Revenue Information
113  Indicate which 
        quarterly filing
        this represents

      Filing due
  November 1, 2026
  February 1, 2027
  May 1, 2027
  August 1, 2027
Historical revenues (lines 115-118) for
July 1 – September 30, 2026
October 1 – December 31, 2026
January 1 – March 31, 2027
April 1 – June 30, 2027
Projected revenues (lines 119-120) for
January 1 – March 31, 2027
April 1 – June 30, 2027
July 1 – September 30, 2027
October 1 – December 31, 2027

114
Check if using safe harbor to allocate interstate/intrastate revenues for each of the following (as applicable):
Cellular & broadband PCS:            Paging:            Analog SMR:            Interconnected VoIP:  
Historical billed revenues with no allowance or deductions for uncollectibles.  See Instructions.
Total Revenues
	(a)	
Interstate Revenues
(b)
International Revenues
(c)
115
Telecommunications provided to other universal service contributors for resale as telecommunications or as interconnected VoIP



116
End-user telecommunications revenues including any pass-through charges for universal service contributions, but excluding international-to-international revenues



117
All other goods and services

Column (b) and (c) not requested
for Lines 117 and 118
118
Gross-billed revenues from all sources [sum of above]


119
Projected gross-billed end-user interstate and international telecommunications revenues including any pass-through charges for universal service contributions, but excluding international-to-international revenues


120
Projected collected end-user interstate and international telecommunications revenues including any pass-through charges for universal service contributions, but excluding international-to-international revenues



Block 4:  CERTIFICATION: to be signed by an officer of the reporting entity

121
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 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  Signature

123  Printed name of officer
First                                                        MI                               Last
124  Position with reporting entity

125  Email of officer (Required if available)

126  Date

127  This filing is:  
  Original filing
 Revised filing [revisions due within 45 days of original filing deadline]

File this form online https://forms.universalservice.org/portal/login 
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 / 2027