FCC Form 499-Q Telecommunications Reporting Worksheet - FCC Form 499-Q

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

Block 1: Contributor Identification Information

Approval by OMB
3060-0855

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/Holding Company Name
[All affiliated companies should show same name here. In most cases,
the Affiliated Filers Name will be the holding company name]
105.1 Affiliated Filers/Holding Company IRS employer identification
number
106 Filer’s FCC Registration Number (FRN)
107 Complete mailing address of reporting entity's corporate headquarters

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

109 Telephone number of this person

(

)

-

110 Fax number of this person

(

)

-

Last

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
Historical revenues (lines 115-118) for
Filing due
quarterly filing
July 1 – September 30, 2014
November 1, 2014
this represents

114

Projected revenues (lines 119-120) for
January 1 – March 31, 2015

February 1, 2015

October 1 – December 31, 2014

April 1 – June 30, 2015

May 1, 2015

January 1 – March 31, 2015

July 1 – September 30, 2015

April 1 – June 30, 2015
October 1 – December 31, 2015
August 1, 2015
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
Total Revenues
uncollectibles. See Instructions.
(a)
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

Interstate Revenues
(b)

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 would
121
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]

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 499@usac.org
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 / September 2014