*Pages 1--7 from DRAFTA1.WK4* 2004 FCC Form 499- A Telecommunications Reporting Worksheet --- DRAFT-- - >>> Please read instructions before completing. <<< Annual Filing -- due April 1. Block 1: Contributor Identification Information During the year, carriers 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 (973)- 560- 4460. 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 reporting entity 103 IRS employer identification number 104 Name telecommunications service provider 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 directions.] All Distance CAP/ CLEC Cellular/ PCS/ SMR (wireless telephony incl. by resale) Coaxial Cable Incumbent LEC Interexchange Carrier (IXC) Local Reseller Operator Service Provider (OSP) 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 If Other Local, Other Mobile or Other Toll is checked, Other Local Other Mobile Other Toll describe carrier type / services provided: --> 106 a Holding company name (All affiliated companies must show the same name on this line.) 106 b Holding company IRS employer identification number 107 FCC Registration Number (FRN) [ https:// svartifoss2. fcc. gov/ cores/ CoresHome. html ] [For assistance, contact the CORES help desk at 877- 480- 3201 or CORES@ fcc. gov] 108 Management company [if carrier is managed by another entity] 109 Complete mailing address of reporting entity corporate headquarters 110 Complete business address for customer inquiries and complaints [if different from address entered on Line 109] 111 Telephone number for customer complaints and inquiries [Toll- free number if available] ( ) - 112 All trade names that you have used in the past 3 years in providing telecommunications. This should include all names by which you are identified on customer bills. g a h b i c j d k e l f m Use an additional sheet if necessary. Each reporting entity must provide all names used for carrier 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 FCC Form 499- A --- DRAFT --- 1 2004 FCC Form 499- A Telecommunications Reporting Worksheet Page 2 Block 2- A: Regulatory Contact Information 201 Filer 499 ID [from Line 101] 202 Legal name of reporting entity [from Line 102] 203 Person who completed this Worksheet 204 Telephone number of this person ( ) - 205 Fax number of this person ( ) - 206 E- mail of this person 207 Corporate office, attn. name, and mailing address to which future Telecommunications Reporting Worksheets should be sent 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. ] Block 2- B: Agent for Service of Process All carriers must complete Lines 209 through 213. During the year, carriers 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 per 47 U. S. C. §413 210 Telephone number of D. C. agent ( ) - 211 Fax number of D. C. agent ( ) - 212 E- mail of D. C. agent 213 Complete business address of D. C. agent for hand service of documents 214 Local/ alternate Agent for Service of Process (optional) 215 Telephone number of local/ alternate agent ( ) - 216 Fax number of local/ alternate agent ( ) - 217 E- mail of local/ alternate agent 218 Complete business address of local/ alternate agent for hand service of documents 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 FCC Form 499- A --- DRAFT --- 2 2004 FCC Form 499- A Telecommunications Reporting Worksheet Page 3 Block 2- C: FCC Registration and Contact Information Carriers 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 reporting entity [from Line 102] 221 Chief Executive Officer (or, highest ranking company officer if the filing entity does not have a chief executive officer) 222 Business address of individual named on Line 221 check if same as Line 109 223 Second ranking company officer, such as Chairman (Must be someone other than the individual listed on Line 221) 224 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 or 223) 226 Business address of individual named on Line 225 check if same as Line 109 227 Indicate jurisdictions in which the filing entity provides telecommunications service. Include jurisdictions in which telecommunications service was provided in the past 15 months and jurisdictions in which telecommunications 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 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 FCC Form 499- A --- DRAFT --- 3 2004 FCC Form 499- A Telecommunications Reporting Worksheet Page 4 Block 3: Carrier's Carrier Revenue Information 301 Filer 499 ID [from Line 101] 302 Legal name of reporting entity [from Line 102] Report billed revenues for January 1 through December 31, 2003. If breakouts are not book Breakouts Do not report any negative numbers. Dollar amounts may be rounded to Total amounts, enter whole the nearest thousand dollars. However, report all amounts as whole dollars. Revenues percentage estimates Interstate International Interstate International Revenues Revenues See instructions regarding percent interstate & international. (a) (b) (c) (d) (e) Revenues from Services Provided for Resale by Other Contributors to Federal Universal Service Support Mechanisms Fixed local service 303 Monthly service, local calling, connection charges, vertical features, and other local exchange service including subscriber line and PICC charges to IXCs a Provided as unbundled network elements (UNEs) b Provided under other arrangements 304 Per- minute charges for originating or terminating calls a Provided under state or federal access tariff b Provided as unbundled network elements or other contract arrangement 305 Local private line & special access service 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 (including 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 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 FCC Form 499- A --- DRAFT--- 4 2004 FCC Form 499- A Telecommunications Reporting Worksheet Page 5 Block 4- A: End- User and Non- Telecommunications Revenue Information 401 Filer 499 ID [from Line 101] 402 Legal name of reporting entity [from Line 102] Report billed revenues for January 1 through December 31, 2003. If breakouts are not book Breakouts Do not report any negative numbers. Dollar amounts may be rounded to Total amounts, enter whole the nearest thousand dollars. However, report all amounts as whole dollars. Revenues percentage estimates Interstate International See instructions regarding percent interstate & international. Interstate International Revenues Revenues (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 404 Monthly service, local calling, connection charges, vertical features, and other local exchange service charges except for federally tariffed subscriber line charges and PICC charges a Provided at a flat rate including interstate toll service b Provided without interstate toll included (see instructions) 405 PICC charges levied by a local exchange carrier on a no- PIC customer and tariffed subscriber line charges 406 Local private line and special access service 407 Payphone coin revenues (local and long distance) 408 Other local telecommunications service revenues Mobile services (including wireless telephony, paging & messaging, and other mobile services) 409 Monthly and activation charges 410 Message charges including roaming, but excluding toll charges 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 412 414 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) 415 Long distance private line services 416 Satellite services 417 All other long distance services 418 Revenues other than U. S. telecommunications revenues. 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.) 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 FCC Form 499- A --- DRAFT--- 5 2004 FCC Form 499- A Telecommunications Reporting Worksheet Page 6 Block 4- B: Total Revenue and Uncollectible Revenue Information Breakouts Total Interstate International Revenues Revenues Revenues (a) (d) (e) 419 Gross billed revenues from all sources [incl. reseller & non- telecom.) [Lines 303 through 314 plus Lines 403 through 418] 420 Universal service contribution base amounts [Lines 403 through 411 & Lines 413 through 417] See Figure 4 in instructions. 421 Uncollectible revenue/ bad debt expense associated with gross billed revenues amounts shown on Line 419 422 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] Block 5: Additional Revenue Breakouts 501 Filer 499 ID [from Line 101] 502 Legal name of reporting entity [from Line 102] Most filers must contribute to LNP administration and must provide the percentages requested in Lines 503 through 510. Filing entities that use Line 603 to certify that they are exempt from this requirement need not provide this information. Block 3 Block 4 Percentage of revenues reported in Block 3 and Block 4 billed in each region of the country. Round or Carrier's End- User estimate to nearest whole percentage. Enter 0 if no service was provided in the region. Carrier 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. (a) (b) Total Revenues Interstate and International Revenues from resellers that do not contribute to Universal Service $ $ 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 FCC Form 499- A --- DRAFT--- 6 2004 FCC Form 499- A Telecommunications Reporting Worksheet Page 7 Block 6: CERTIFICATION: to be signed by an officer of the filer 601 Filer 499 ID [from Line 101] 602 Legal name of reporting entity [from Line 102] Section IV of the instructions provides information on which types of reporting entities are required to file for which purposes. Any entity 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 entities 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 reporting entity is exempt from contributing to: Universal Service TRS NANPA LNP Administration Provide explanation below: 604 Please indicate whether the reporting entity is State or Local Government Entity I. R. C. § 501Tax Exempt PUHCA § 34 (a)( 1) Exempt 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 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 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 reporting entity 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- B of the instructions. 606 Signature 607 Printed name of officer 608 Position with reporting entity 609 Business telephone number of officer 610 E- mail of officer 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 NECA, 80 South Jefferson Road, Whippany, New Jersey 07981 For additional information regarding this worksheet contact: Telecommunications Reporting Worksheet information: (973) 560- 4460 or via e- mail: 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 For information on filing electronically go to http:// form499. universalservice. org/ FCC Form 499- A --- DRAFT --- 7