Official Federal Forms > Federal Communications Commission (FCC)
Telecommunications Reporting Worksheet Quarterly Filing For Universal Service Contributors 499-Q - Official Federal Forms
| Telecommunications Reporting Worksheet Quarterly Filing For Universal Service Contributors Form. This is a national form and can be used in Federal Communications Commission (FCC) . |
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FCC Form 499-Q Telecommunications Reporting Worksheet Quarterly Filing for Universal Service Contributors > Please read instructions before completing < Block 1: Contributor Identification Information 102 Legal name of reporting entity 103 Filer's IRS employer identification number 104 Name telecommunications provider is doing business as 105 Holding company [All affiliated companies should show same name here.] 105.1 Holding company IRS employer identification number 106 Filer's FCC Registration Number (FRN) 107 Complete mailing address of reporting entity's corporate headquarters Block 2: Contact Information 108 Person who completed this worksheet 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 quarterly filing November 1, 2012 July 1 September 30, 2012 this represents February 1, 2013 May 1, 2013 August 1, 2013 114 Cellular & broadband PCS: October 1 December 31, 2012 January 1 March 31, 2013 First MI Last Approval by OMB 3060-0855 101 Filer 499 ID Check if filer has no affiliates: [Enter 9 digit number] [Enter 10 digit number] ( ( ) ) - Projected revenues (lines 119-120) for January 1 March 31, 2013 April 1 June 30, 2013 July 1 September 30, 2013 April 1 June 30, 2013 October 1 December 31, 2013 ntrastate revenues for each of the following (as applicable): Paging: Analog SMR: Interconnected VoIP: Interstate Revenues (b) International Revenues (c) Total Revenues Historical billed revenues with no allowance or deductions for (a) uncollectibles. See Instructions. Telecommunications provided to other universal service 115 contributors for resale as telecommunications or as interconnected VoIP End-user telecommunications revenues including any 116 pass-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 119 revenues including any pass-through charges for universal service contributions, but excluding international-to-international revenues Projected collected end-user interstate and international telecommunications 120 revenues including any pass-through charges for universal service contributions, but excluding international-to-international revenues 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 121 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 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 499@universalserivce.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 First MI Last Save time, avoid problems file electronically at http://forms.universalservice.org FCC Form 499-Q / February 2013 American LegalNet, Inc. www.FormsWorkFlow.com
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