Fcc Form 499-Q Telecommunications Reporting Worksheet printable pdf download

FCC Form 499-Q Telecommunications Reporting Worksheet

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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

Check if filer has no affiliates:

[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

[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

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, 2015

January 1 – March 31, 2016

November 1, 2015

this represents

October 1 – December 31, 2015

April 1 – June 30, 2016

February 1, 2016

January 1 – March 31, 2016

July 1 – September 30, 2016

May 1, 2016

April 1 – June 30, 2016

October 1 – December 31, 2016

August 1, 2016

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:

Total Revenues

Interstate Revenues

International Revenues

Historical billed revenues with no allowance or deductions for

uncollectibles. See Instructions.

(a)

(b)

(c)

Telecommunications provided to other universal service

115

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

First

Last

123 Printed name of officer

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

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

FCC Form 499-Q /January 2016

Fcc Form 499-Q Telecommunications Reporting Worksheet

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