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DA-13-2090A2

PN ATTACHMENT 1 DRAFT FCC FORM 499-A / PAGE 1

2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 Revenues) APPROVED BY OMB
3060-0855
>>> Please read instructions before completing.<<<

Annual Filing -- due April 1, 2014

Block 1: Contributor Identification Information

During the year, filers must refile Blocks 1, 2 and 6 if there are any changes in Lines 104 or 112. See Instructions.
101
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.]
102
Legal name of filer
103
IRS employer identification number
[Enter 9 digit number]
104
Name filer is doing business as
105
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.]
Audio Bridging (teleconferencing) Provider
CAP/CLEC
Cellular/PCS/SMR (wireless telephony inc. by resale)
Coaxial Cable
Incumbent LEC
Interconnected VoIP
Interexchange Carrier (IXC)
Local Reseller
Non-Interconnected VoIP
Operator Service Provider
Paging & Messaging
Payphone Service Provider
Prepaid Card
Private Service Provider
Satellite Service Provider
Shared-Tenant Service Provider / Building LEC
SMR (dispatch)
Toll Reseller
Wireless Data
Other Local
Other Mobile
Other Toll
If Other Local, Other Mobile or Other Toll is checked

describe carrier type / services provided:
106.1
Affiliated Filers Name/Holding Company Name (All affiliated companies must show the same name on this line.)
Check if filer has no affiliates
106.2
Affiliated Filers Name/Holding Company Name IRS employer identification number
[Enter 9 digit number]
107
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]
[Enter 10 digit number]
108
Management company [if filer is managed by another entity]
109
Complete mailing address of reporting entity corporate headquarters
Street1
Street2
Street3
City State Zip (postal code) Country if not USA
110
Complete business address for customer inquiries and complaints
Street1
Street2
check if same address as Line 109
Street3
City State Zip (postal code) Country if not USA
111
Telephone number for customer complaints and inquiries [Toll-free number if available]
( ) - ext -
112
List all trade names used in the past 3 years in providing telecommunications. Include all names by which you are known by customers.
a
g
b
h
c
i
d
j
e
k
f
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 / December 2013 [[DRAFT]]

DRAFT FCC FORM 499-A / PAGE 2

2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 Revenues) Page 2

Block 2-A: Regulatory Contact Information
201

Filer 499 ID [from Line 101]
202
Legal name of filer [from Line 102]
203
Person who completed this Worksheet
First MI Last
204
Telephone number of this person
( ) - ext -
205
Fax number of this person
( ) -
206
Email of this person  not for public release
207
Corporate office, attn. name, and mailing address to which future
Office Attn: First name MI Last
Telecommunications Reporting Worksheets should be sent
Email  not for public release Phone ( ) - ext- Fax ( ) -
check if same name as Line 203
- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - -
check if same address as Line 109
Street1
Street2
Street3
City State Zip (postal code) Country if not USA
208
Billing address and billing contact person
Company Attn: First name MI Last
[Plan administrators will send bills for contributions to this
address. Please attach a written request for alternative billing
Email  not for public release Phone ( ) - ext- Fax ( ) -
arrangements.]
- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - -
Street1
check if name and address same as Line 207
Street2
Street3
City State Zip (postal code) Country if not USA
208.1
Email address pertaining to ITSP regulatory fee issues
 not for public release

Block 2-B: Agent for Service of Process

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
209
D.C. Agent for Service of Process
Company 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
213
Street1
Complete business address of D.C. agent
Street2
for hand service of documents
Street3
City State DC Zip
214
Local/alternate Agent for Service of Process (optional)
Company 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
218
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 / December 2013 [[DRAFT]]

DRAFT FCC FORM 499-A / PAGE 3

2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 Revenues) Page 3

Block 2-C: FCC Registration and Contact Information

Filers must refile Blocks 1, 2 and 6
if there are any changes in this section. See Instructions.
219
Filer 499 ID [from Line 101]
220
Legal name of filer [from Line 102]
221
Chief Executive Officer (or, highest ranking company officer if
First MI Last
the filer does not have a chief executive officer)
222
Business address of individual named on Line 221
Street1
Street2
Street3
check if same as Line 109
City State Zip (postal code) Country if not USA
223
Second ranking company officer, such as Chairman
First MI Last
(Must be someone other than the individual listed on Line 221)
224
Business address of individual named on Line 223
Street1
Street2
Street3
check if same as Line 109
City State Zip (postal code) Country if not USA
225
Third ranking company officer, such as President or Secretary
First MI Last
(Must be someone other than individuals listed on Lines 221 and
223)
226
Business address of individual named on Line 225
Street1
check if same as Line 109
Street2
Street3
City State Zip (postal code) Country if not USA
227
Indicate jurisdictions in which the filer provides service. Include jurisdictions in which service was provided in the past 15 months
and jurisdictions in which service is likely to be provided in the next 12 months.
Alabama
Guam
Massachusetts
New York
Tennessee
Alaska
Hawaii
Michigan
North Carolina
Texas
American Samoa
Idaho
Midway Atoll
North Dakota
Utah
Arizona
Illinois
Minnesota
Northern Mariana Islands
U.S. Virgin Islands
Arkansas
Indiana
Mississippi
Ohio
Vermont
California
Iowa
Missouri
Oklahoma
Virginia
Colorado
Johnston Atoll
Montana
Oregon
Wake Island
Connecticut
Kansas
Nebraska
Pennsylvania
Washington
Delaware
Kentucky
Nevada
Puerto Rico
West Virginia
District of Columbia
Louisiana
New Hampshire
Rhode Island
Wisconsin
Florida
Maine
New Jersey
South Carolina
Wyoming
Georgia
Maryland
New Mexico
South Dakota
228
Year and month filer first provided (or expects to provide) telecommunications in the U.S.
Check if prior to 1/1/1999, otherwise:
Year
Month
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 / December 2013 [[DRAFT]]

DRAFT FCC FORM 499-A / PAGE 4

2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 Revenues) Page 4

Block 3: Carrier’s Carrier Revenue Information

301
Filer 499 ID [from Line 101]
302
Legal name of filer [from Line 102]
Report billed revenues for January 1 through December 31, 2013.
If breakouts are not book
Breakouts
Do not report any negative numbers. Dollar amounts may be rounded to the nearest thousand dollars.
amounts, enter whole
Interstate
International
However, report all amounts as whole dollars.
Total Revenues
percentage estimates
Revenues
Revenues
(a)
Interstate
International
See instructions regarding percent interstate and international.
(b)
(c)
(d)
(e)

Revenues from Services Provided for Resale as Telecommunications
by Other Contributors to Federal Universal Service Support Mechanisms

Fixed local service


Monthly service, local calling, connection charges, vertical features,
and other local exchange service including subscriber line and
303.1
PICC charges to IXCs
Provided as unbundled network elements (UNEs)
303.2
Provided under other arrangements
Per-minute charges for originating or terminating calls
304.1
Provided under state or federal access tariff
304.2
Provided as unbundled network elements or other contract arrangement
Local private line & special access service
305.1
Provided to other contributors for resale as telecommunications
305.2
Provided to other contributors for resale as interconnected VoIP
306
Payphone compensation from toll carriers
307
Other local telecommunications service revenues
308
Universal service support revenues received from Federal or state sources
Mobile services (i.e., wireless telephony, paging, messaging, and other mobile services)
309
Monthly, activation, and message charges except toll
Toll services
310
Operator and toll calls with alternative billing arrangements (credit card, collect,
international call-back, etc.)
311
Ordinary long distance(direct-dialed MTS, customer toll-free (800/888
etc.) service, “10-10” calls, associated monthly account maintenance,
PICC pass-through, and other switched services not reported above)
312
Long distance private line services
313
Satellite services
314
All other long distance services
315
Total revenues from resale [Lines 303 through 314]

See section III.C.2 of the instructions for the requirements applicable to revenue reported on this page. These records must be made available to the administrator or the FCC
upon request.

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 / December 2013 [[DRAFT]]

DRAFT FCC FORM 499-A / PAGE 5

2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 Revenues) Page 5

Block 4-A: End-User and Non-Telecommunications Revenue Information
401

Filer 499 ID [from Line 101]
402
Legal name of filer [from Line 102]
Report billed revenues for January 1 through December 31, 2013.
If breakouts are not book
Breakouts
Do not report any negative numbers. Dollar amounts may be rounded to
Total Revenues
amounts, enter whole
Interstate
International
the nearest thousand dollars. However, report all amounts as whole dollars.
percentage estimates
Revenues
Revenues
Interstate
International
See instructions regarding percent interstate and international.
(a)
(b)
(c)
(d)
(e)

Revenues from All Other Sources (end-user, telecom. & non-telecom.)
403

Surcharges or other amounts on bills identified as recovering
State or Federal universal service contributions

Fixed local services


Monthly service, local calling, connection charges, vertical features,
and other local exchange service charges except for federally
tariffed subscriber line charges and PICC charges
Traditional Circuit Switched
404.1
Provided at a flat rate including interstate toll service – local portion
404.2
Provided at a flat rate including interstate toll service – toll portion
404.3
Provided without interstate toll included (see instructions)
Interconnected VoIP
404.4
Offered in conjunction with a broadband connection
404.5
Offered independent of a broadband connection
405
Tariffed subscriber line charges, Access Recovery Charges, and PICC charges levied by a
local exchange carrier on a no-PIC customer
406
Local private line & special access service [Includes the transmission
portion of wireline broadband Internet access provided on a common
carrier basis.]
407
Payphone coin revenues (local and long distance)
408
Other local telecommunications service revenues

Mobile services (i.e., wireless telephony, paging, messaging, and other mobile services)

409
Monthly and activation charges
410
Message charges including roaming and air-time charges for toll
calls, but excluding separately stated toll charges
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 / December 2013 [[DRAFT]]

DRAFT FCC FORM 499-A / PAGE 6

2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 Revenues) Page 6

Block 4-A: Continued

If breakouts are not book
Breakouts
Total Revenues
amounts, enter whole
Interstate
International
percentage estimates
Revenues
Revenues
Interstate
International
(a)
(b)
(c)
(d)
(e)
Toll services
411
Prepaid calling card (including card sales to customers)
and non-carrier distributors) reported at face value of cards
412
International calls that both originate and terminate in foreign points
0%
100%
413
Operator and toll calls with alternative billing arrangements (credit
card, collect, international call-back, etc.) other than revenues
reported on Line 412
Ordinary long distance (direct-dialed MTS, customer toll-free (800/888
etc.) service, “10-10” calls, associated monthly account maintenance,
PICC pass-through, and other switched services not reported above)
414.1
All, other than interconnected VoIP, including, but not limited to,
itemized toll on wireline and wireless bills
414.2
All interconnected VoIP long distance, including, but not limited to,
itemized toll
415
Long distance private line services
416
Satellite services
417
All other long distance services
Revenues other than U.S. telecommunications revenues, including information services,
inside wiring maintenance, billing and collection, customer premises equipment, published
directory, dark fiber, Internet access, cable TV program transmission, foreign carrier
operations, and non-telecommunications revenues (See instructions)
418.1
bundled with circuit switched local exchange service
418.2
bundled with interconnected VoIP local exchange service
418.3
Other
418.4
non-interconnected VoIP revenues not included in any other category

Block 4-B: Total Revenue and Uncollectible Revenue Information

419
Gross billed revenues from all sources (incl. reseller & non-telecom.)
[Lines 303 through 314 plus Lines 403 through 418]
420
Gross universal service contribution base amounts [Lines 403 through 411 plus
Lines 413 through 417] [See Table 3 in instructions.]
421
Uncollectible revenue/bad debt expense associated with gross
billed revenues amounts shown on Line 419 [See instructions.]
422
Uncollectible revenue/bad debt expense associated with universal
service contribution base amounts shown on Line 420
423
Net universal service contribution base revenues
[Line 420 minus line 422]
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 / December 2013 [[DRAFT]]

DRAFT FCC FORM 499-A / PAGE 6

2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 Revenues) Page 7

Block 5: Additional Revenue Breakouts

501
Filer 499 ID [from Line 101]
502
Legal name of filer [from Line 102]
Filers that report revenues in Block 3 and Block 4 must provide the percentages requested in Lines 503 through 510.
See instructions for limited exceptions.
Percentage of revenues reported in Block 3 and Block 4 billed in each region of the country. Round or
Block 3
Block 4
estimate to nearest whole percentage. Enter 0 if no service was provided in the region.
Carrier’s Carrier
End-User 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-B, 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. As stated in the instructions, you must have in your records the FCC Filer 499 ID for each customer
whose revenues are included on Line 511. (See instructions.)

(a)
(b)
Total Revenues
Interstate and International
Revenues from resellers that do not contribute to Universal Service
512
Gross TRS contribution base amounts
[Lines 403 through 417 plus Line 418.4 less Line 511]
513
Uncollectible revenue/bad debt expense associated with TRS contribution base amounts
shown on Line 512
514
Net TRS contribution base revenues [Line 512 less Line 513]
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 / December 2013 [[DRAFT]]

DRAFT FCC FORM 499-A / PAGE 6

2014 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2013 Revenues) Page 8

Block 6: CERTIFICATION: to be signed by an officer of the filer

601
Filer 499 ID [from Line 101]
602
Legal name of filer [from Line 102]
Section IV of the instructions provides information on which types of filers are required to file for which purposes. Any filer claiming
to be exempt from one or more contribution requirements should so certify below and attach an explanation. [The Universal Service Administrator
will determine which filers meet the de minimis threshold based on information provided in Block 4, even if you fail to so certify below.]
603
I certify that the filer is exempt from contributing to:
Universal Service
TRS
NANPA
LNP Administration
Provide explanation below:
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
604
Please indicate whether the filer is

State or Local Government Entity


I.R.C. § 501 or State Tax Exempt (see instructions)


605
I certify that the revenue data contained herein are privileged and confidential and that public disclosure of such information 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 filer as defined in the instructions, 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 and that said Worksheet is an accurate statement of the
affairs of the above-named company for the previous calendar year. In addition, I swear, under penalty of perjury, that all requested identification
registration information has been provided and is accurate. If the above-named filer is filing on a consolidated basis, I certify that this filing incorporates
all of the revenues for the consolidated entities for the entire year and that the filer adhered to and continues to meet the conditions set forth in section II-
C of the instructions.
606
Signature
______________________________________________________________________________
607
Printed name of officer
First MI Last
608
Position with reporting entity
609
Business telephone number of officer
( ) - ext -
610
Email of officer  not for public release
611
Date
612
Check those that apply
Original April 1 filing for year
New filer, registration only
Revised filing with updated registration
Revised filing with updated revenue data
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 information: (888) 641-8722 or via email: Form499@universalservice.org
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 / December 2013 [[DRAFT]]

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