2009 Fcc Form 499-A - Telecommunications Reporting Worksheet (Reporting Calendar 2008 Revenues) Page 2
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82009 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2008 Revenues)
Page 2
Block 2-A: Regulatory Contact Information
201 Filer 499 ID [from Line 101]
202 Legal name of reporting entity [from Line 102]
First
MI
Last
203 Person who completed this Worksheet
204 Telephone number of this person
(
) -
ext -
205 Fax number of this person
(
) -
206 Email of this person || Required if available -- not for public release ||
Office
207 Corporate office, attn. name, and mailing
Attn First name
MI
Last
Email ||required if available, not for public release||
address to which future Telecommunications
Phone
(
) -
ext-
Fax
(
) -
Street1
Reporting Worksheets should be sent
check if same name as Line 203
Street 2
check if same address as Line 109
Street 3
City
State
Zip (postal code)
Country if not USA
Company
208 Billing address and billing contact person:
Attn First name
MI
Last
Email ||required if available, not for public release||
[Plan administrators will send bills for contributions to this
Phone
(
) -
ext-
Fax
(
) -
Street1
address. Please attach a written request for alternative
Street 2
billing arrangements. ]
check if name and address same as Line 207
Street 3
check to use Line 208 information for FCC ITSP regulatory fee bill
City
State
Zip (postal code)
Country if not USA
All carriers and providers of interconnected VoIP must complete Lines 209 through 213. During the year, carriers
Block 2-B: Agent for Service of Process
and providers of interconnected VoIP must refile Blocks 1, 2 and 6 if there are any changes in this section. See Instructions.
Company
209 D.C. Agent for Service of Process per 47 U.S.C. § 413
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
|| Required if available ||
Street1
213 Complete business address of D.C. agent
Street 2
for hand service of documents
check to use Line 213 information for FCC ITSP regulatory fee bill
Street 3
[If both Line 208 and Line 213 are checked, Line 208 will be used.}
City
State
Zip
DC
Company
214 Local/alternate Agent for Service of Process (optional)
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
|| Required if available ||
Street1
218 Complete business address of local/alternate
Street 2
agent for hand service of documents
check to use Line 218 information for FCC ITSP regulatory fee bill
Street 3
[If both Line 208 and Line 218 are checked, Line 208 will be used.}
City
State
Zip (postal code)
Country if not USA
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
Save time, avoid problems -- file electronically at
FCC Form 499-A
February 2009
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