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Form 499-A

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Released: March 1, 2013
2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 Revenues) APPROVED BY OMB

3060-0855
>>> Please read instructions before completing.<<<

Annual Filing -- due April 1, 2013


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
Holding company name (All affiliated companies must show the same name on this line.)
Check if filer has no affiliates

106.2
Holding company 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/">http://forms.universalservice.org
FCC Form 499-A / February 2013



2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 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
- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - -
Street1
check if same address as Line 109
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/">http://forms.universalservice.org
FCC Form 499-A / February 2013



2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 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
Street2
check if same as Line 109
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/">http://forms.universalservice.org
FCC Form 499-A / February 2013



2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 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, 2012.

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]





Except as noted in the Instructions, for all revenues reported on this page, you must: (1) retain the Filer 499 ID and contact information for the associated customers, (2) verify
that each of these customers was a “reseller “for calendar year 2012, and (3) verify that the customer is purchasing service for resale as telecommunications. 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/">http://forms.universalservice.org
FCC Form 499-A / February 2013



2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 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, 2012.

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/">http://forms.universalservice.org
FCC Form 499-A / February 2013



2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 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/">http://forms.universalservice.org
FCC Form 499-A / February 2013



2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 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/">http://forms.universalservice.org
FCC Form 499-A / February 2013



2013 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting 2012 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

Universal Service 
TRS 
NANPA 
LNP Administration 
I certify that the filer is exempt from contributing to:


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/">http://forms.universalservice.org
FCC Form 499-A / February 2013


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