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PN ATTACHMENT 3 DRAFT FCC FORM 499-Q / PAGE 1

FCC Form 499-Q Telecommunications Reporting Worksheet

Approval by OMB

Quarterly Filing for Universal Service Contributors

> Please read instructions before completing < 3060-0855

Block 1: Contributor Identification Information

101 Filer 499 ID
102 Legal name of reporting entity
103 Filer’s IRS employer identification number
104 Name telecommunications provider is doing business as
105 Affiliated Filers Name
Check if filer has no affiliates:
[All affiliated companies should show same name here. In most cases, the
Affiliated Filers Name will be the holding company name. See instructions at
10-11.]
105.1 Affiliate Filers Name IRS employer identification number
[Enter 9 digit number]
106 Filer’s FCC Registration Number (FRN)
[Enter 10 digit number]
107 Complete mailing address of reporting entity's corporate headquarters

Block 2: Contact Information
108

Person who completed this worksheet
First MI Last
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

Projected revenues (lines 119-120) for

quarterly filing
this represents
November 1, 2014
July 1 – September 30, 2014
January 1 – March 31, 2015
February 1, 2014
October 1 – December 31, 2013
April 1 – June 30, 2014
May 1, 2014
January 1 – March 31, 2014
July 1 – September 30, 2014
August 1, 2014
April 1 – June 30, 2014
October 1 – December 31, 2014
114
Check if using safe harbor to allocate interstate/intrastate revenues for each of the following (as applicable):
Cellular & broadband PCS: Paging: Analog SMR: Interconnected VoIP:
Historical billed revenues with no allowance or deductions for
Total Revenues
Interstate Revenues
International Revenues
uncollectibles. See Instructions.
(a)
(b)
(c)
115
Telecommunications provided to other universal service
contributors for resale as telecommunications or as
interconnected VoIP
116
End-user telecommunications revenues including any pass-
through charges for universal service contributions, but
excluding international-to-international revenues
117
All other goods and services
Column (b) and (c) not requested
118
Gross-billed revenues from all sources [sum of above]
for Lines 117 and 118
119
Projected gross-billed end-user interstate and international telecommunications revenues
including any pass-through charges for universal service contributions, but excluding
international-to-international revenues
120
Projected collected end-user interstate and international telecommunications revenues
including any pass-through charges for universal service contributions, but excluding
international-to-international revenues

Block 4: CERTIFICATION: to be signed by an officer of the reporting entity
121

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 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
First MI Last
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

Save time, avoid problems – file electronically at
http://forms.universalservice.org
FCC Form 499-Q December 2013

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