2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues) Approval by OMB >>> Please read instructions before completing. <<< 3060-0855 Annual Filing -- due April 1, 2011 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 reporting entity 103 IRS employer identification number [Enter 9 digit number] 104 Name telecommunications 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 instructions.] Audio Bridging (teleconferencing) Provider CAP/CLEC Cellular/PCS/SMR (wireless telephony incl. by resale) Coaxial Cable Incumbent LEC Interconnected VoIP 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: 106.1 Holding company name (All affiliated companies must show the same name on this line.) 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 Street1 corporate headquarters 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. ag b h ci dj ek fl Use an additional sheet if necessary. Each reporting entity 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 / March 2011 2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues) 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 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 Office Attn: First name MI Last address to which future Telecommunications Email ||not for public release|| Phone ( ) - ext- Fax ( ) - Reporting Worksheets should be sent Street1 check if same name as Line 203 Street2 check if same address as Line 109 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 Email ||not for public release|| Phone ( ) - ext- Fax ( ) - address. Please attach a written request for alternative Street1 billing arrangements. ] Street2 check if name and address same as Line 207 Street3 City State Zip (postal code) Country if not USA 208.1 Email address where ITSP regulatory fee bill should be sent ||not for public release|| Block 2-B: Agent for Service of Process All carriers and providers of interconnected VoIP must complete Lines 209 through 213. During the year, carriers and providers of interconnected VoIP 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 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 Complete business address of D.C. agent Street1 for hand service of documents Street2 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 Complete business address of local/alternate Street1 agent for hand service of documents Street2 Street3 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 / March 2011 2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 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 reporting entity [from Line 102] 221 Chief Executive Officer (or, highest ranking company officer First MI Last if the filing entity does not have a chief executive officer) 222 Business address of individual named on Line 221 Street1 Street2 check if same as Line 109 Street3 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 check if same as Line 109 Street3 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 filing entity 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 / March 2011 2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues) 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, 2010. 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 and international (a) (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 PICC charges to IXCs 303.1 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] Note: As stated in the instructions, for all revenues reported on this page, you must retain the Filer 499 ID and contact information for the associated customers. You must verify that each of these customers was a direct contributor to the federal universal service support mechanism for calendar year 2010 and that the customer is purchasing service for resale as telecommunications. These records must be made available to the administrator or the FCC upon request. The FCC website contains information on federal universal service contributors. (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 Save time, avoid problems -- file electronically at http://forms.universalservice.org FCC Form 499-A / March 2011 2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues) 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, 2010. 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 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 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 / March 2011 2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues) Page 6 Block 4-A: Continued If breakouts are not book Breakouts amounts, enter whole Total percentage estimates Interstate International Revenues Interstate International Revenues Revenues (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 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 / March 2011 2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 Revenues) Page 7 Block 5: Additional Revenue Breakouts 501 Filer 499 ID [from Line 101] 502 Legal name of reporting entity [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. 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. 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 $ $ 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 / March 2011 2011 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2010 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 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. § 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 reporting entity 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 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-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 / March 2011