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Telecommunications Reporting Worksheet (Annual Filing) 499-A - Official Federal Forms
| Telecommunications Reporting Worksheet (Annual Filing) Form. This is a national form and can be used in Federal Communications Commission (FCC) . |
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2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 Revenues) >>> Please read instructions before completing.<<< Annual Filing -- due April 1, 2013 APPROVED BY OMB 3060-0855 Block 1: Contributor Identification Information 101 102 103 104 105 During the year, filers must refile Blocks 1, 2 and 6 if there are any changes in Lines 104 or 112. See Instructions. Filer 499 ID [If you don't know your number, contact the administrator at (888) 641-8722. If you are a new filer, write "NEW" in this block and a Filer 499 ID will be assigned to you.] Legal name of filer IRS employer identification number Name filer is doing business as Telecommunications activities of filer [Select up to 5 boxes that best describe the reporting entity. Enter numbers starting with "1" to show the order of importance -- see instructions.] [Enter 9 digit number] Audio Bridging (teleconferencing) Provider Coaxial Cable Non-Interconnected VoIP Private Service Provider Toll Reseller Incumbent LEC Operator Service Provider Satellite Service Provider Wireless Data CAP/CLEC Interconnected VoIP Paging & Messaging Cellular/PCS/SMR (wireless telephony inc. by resale) Interexchange Carrier (IXC) Payphone Service Provider Local Reseller Prepaid Card SMR (dispatch) Other Toll Shared-Tenant Service Provider / Building LEC Other Local Other Mobile If Other Local, Other Mobile or Other Toll is checked describe carrier type / services provided: 106.1 106.2 107 108 109 Holding company name (All affiliated companies must show the same name on this line.) Holding company IRS employer identification number FCC Registration Number (FRN) [https://fjallfoss.fcc.gov/coresWeb/publicHome.do] [For assistance, contact the CORES help desk at 877-480-3201 or CORES@fcc.gov] Management company [if filer is managed by another entity] Complete mailing address of reporting entity corporate headquarters Street1 Street2 Street3 City Street1 Street2 Street3 City Check if filer has no affiliates [Enter 9 digit number] [Enter 10 digit number] State Zip (postal code) Country if not USA 110 Complete business address for customer inquiries and complaints check if same address as Line 109 State ( g h i j ) - Zip (postal code) ext - Country if not USA 111 112 Telephone number for customer complaints and inquiries [Toll-free number if available] a b c d e f List all trade names used in the past 3 years in providing telecommunications. Include all names by which you are known by customers. k l Use additional sheets if necessary. Each filer must provide all names used for telecommunications activities 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 http://forms.universalservice.org FCC Form 499-A / February 2013 American LegalNet, Inc. www.FormsWorkFlow.com 2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 Revenues) Block 2-A: Regulatory Contact Information 201 202 203 204 205 206 207 Filer 499 ID [from Line 101] Legal name of filer [from Line 102] Person who completed this Worksheet Telephone number of this person Fax number of this person Email of this person ||not for public release|| Corporate office, attn. name, and mailing address to which future Telecommunications Reporting Worksheets should be sent check if same name as Line 203 check if same address as Line 109 Page 2 First ( ( Office ) ) - MI ext - Last Attn: First name MI Last 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.] check if name and address same as Line 207 Email ||not for public release|| Phone ( )extFax ( ) - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - Street1 Street2 Street3 City State Zip (postal code) Country if not USA Company Attn: First name MI Last Email ||not for public release|| Phone ( )extFax ( ) - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - Street1 Street2 Street3 City State Zip (postal code) Country if not USA ||not for public release|| All carriers and providers of interconnected and non-interconnected VoIP must complete Lines 209 through 213. During the year, these filers must refile Blocks 1, 2, and 6 if there are any changes in this section. See Instructions Company Attn: First name MI Last ( ) ext ( ) Street1 Street2 Street3 City Company ( ( ) ) 208.1 Email address pertaining to ITSP regulatory fee issues Block 2-B: Agent for Service of Process 209 210 211 212 213 D.C. Agent for Service of Process Telephone number of D.C. agent Fax number of D.C. agent Email of D.C. agent Complete business address of D.C. agent for hand service of documents 214 215 216 217 218 Local/alternate Agent for Service of Process (optional) Telephone number of local/alternate agent Fax number of local/alternate agent Email of local/alternate agent State DC - Zip Attn: First name ext MI Last Street1 Complete business address of local/alternate agent Street2 for hand service of documents 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 http://forms.universalservice.org FCC Form 499-A / February 2013 American LegalNet, Inc. www.FormsWorkFlow.com 2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 Revenues) Block 2-C: FCC Registration and Contact Information 219 220 221 222 Filer 499 ID [from Line 101] Legal name of filer [from Line 102] Chief Executive Officer (or, highest ranking company officer if the filer does not have a chief executive officer) Business address of individual named on Line 221 check if same as Line 109 223 224 Second ranking company officer, such as Chairman (Must be someone other than the individual listed on Line 221) Business address of individual named on Line 223 check if same as Line 109 225 Third ranking company officer, such as President or Secretary (Must be someone other than individuals listed on Lines 221
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