Fcc Form 499-A - Telecommunications Reporting Worksheet - 2003 Page 6
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342003 FCC Form 499-A Telecommunications Reporting Worksheet
Page 6
Block 5: Additional Revenue Breakouts
501 Filer 499 ID [from Line 101]
502 Legal name of reporting entity [from Line 102]
Most filers must contribute to LNP administration and must provide the percentages requested in Lines 503 through 510.
Filing entities that use Line 603 to certify that they are exempt from this requirement need not provide this information.
Block 3
Block 4
Percentage of revenues reported in Block 3 and Block 4 billed in each region of the country. Round or
Carrier's
End-User
estimate to nearest whole percentage. Enter 0 if no service was provided in the region.
Carrier
Telecom.
(a)
(b)
503
Southeast:
Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina,
%
%
Puerto Rico, South Carolina, Tennessee, and U.S. Virgin Islands
504
Western:
Alaska, Arizona, Colorado, Idaho, Iowa, Minnesota, Montana, Nebraska, New Mexico,
%
%
North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming
505
West Coast:
California, Hawaii, Nevada, American Samoa, Guam, Johnston Atoll, Midway Atoll,
%
%
Northern Mariana Islands, and Wake Island.
506
Mid-Atlantic:
Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania, Virginia, and
%
%
West Virginia
507
Mid-West:
Illinois, Indiana, Michigan, Ohio, and Wisconsin
%
%
508
Northeast:
Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont
%
%
509
Southwest:
Arkansas, Kansas, Missouri, Oklahoma, and Texas
%
%
510
Total
[Percentages must add to 0 or 100.]
%
%
511
Revenues from resellers that do not contribute to Universal Service support mechanisms are included in Block 4, Line 420 but may be excluded
from a filer's TRS, NANPA, LNP, and FCC interstate telephone service provider regulatory fee contribution bases. To have these amounts excluded,
the filer has the option of identifying such revenues below.
(a)
(b)
Total Revenues
Interstate and International
Revenues from resellers that do not contribute to Universal Service
$
$
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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