Fcc Form 499-A - Telecommunications Reporting Worksheet - 2003 Page 2
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342003 FCC Form 499-A Telecommunications Reporting Worksheet
Page 2
Block 2-A: Regulatory Contact Information
201 Filer 499 ID [from Line 101]
202 Legal name of reporting entity [from Line 102]
203 Person who completed this worksheet
204 Telephone number of this person
(
) -
205 Fax number of this person
(
) -
206 E-mail of this person
207 Corporate office, attn. name, and mailing
address to which future Telecommunications
Reporting Worksheets should be sent
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. ]
Block 2-B: Agent for Service of Process
All carriers must complete Lines 209 through 213.
During the year, carriers 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 per 47 U.S.C. 413
210 Telephone number of D.C. agent
(
) -
211 Fax number of D.C. agent
(
) -
212 E-mail of D.C. agent
213 Complete business address of D.C. agent
for hand service of documents
214 Local/alternate Agent for Service of Process (optional)
215 Telephone number of local/alternate agent
(
) -
216 Fax number of local/alternate agent
(
) -
217 E-mail of local/alternate agent
218 Complete business address of local/alternate
agent for hand service of documents
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
FCC Form 499-A
February 2003
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