2006 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2005 Revenues) >>> Please read instructions before completing. <<< Annual Filing due April 1, 2006 Revised Block 1: Contributor Identification Information Approval by OMB 3060-0855 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.] 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 111 Telephone number for customer complaints and inquiries [Toll-free number if available] 112 List all trade names used in the past 3 years in providing telecommunications. Include all names by which you are known by customers. 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 http://forms.universalservice.org FCC Form 499-A (revised) August 2006 2006 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2005 Revenues) Block 2-A: Regulatory Contact Information check if name and address same as Line 207 All carriers and providers of interconnected VoIP must complete Lines 209 through 213. During the year, carriers 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 http://forms.universalservice.org Save time, avoid problems file electronically at FCC Form 499-A (revised) August 2006 2006 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2005 Revenues) 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. 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 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 (revised) August 2006 2006 FCC Form 499-A Telecommunications Reporting Worksheet (Reporting Calendar 2005 Revenues) Block 3: Carrier's Carrier Revenue Information Page 4 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 2005 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 (revised) August 2006 |