FCC Form 499-Q Telecommunications Reporting Worksheet Approval by OMBQuarterly 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 Filer222s IRS employer identification number 104 Name telecommunications provider is doing business as 105 Affiliated Filers Name [All affiliated companies should show same name here. In most cases, the Affiliated Filers Name will be the holding company name Check if filer has no affiliates: 105.1 Affiliate Filers Name IRS employer identification number [Enter 9 digit number] 106 Filer222s 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 quarterly filing this represents Filing due November 1, 2018 February 1, 2019 May 1, 2019 August 1, 2019 Historical revenues (lines 115-118) for July 1 226 September 30, 2018October 1 226 December 31, 2018January 1 226 March 31, 2019April 1 226 June 30, 2019 Projected revenues (lines 119-120) for January 1 226 March 31, 2019April 1 226 June 30, 2019July 1 226 September 30, 2019October 1 226 December 31, 2019 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 uncollectibles. See Instructions. Total Revenues(a) Interstate Revenues(b) International Revenues(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 118 Gross-billed revenues from all sources [sum of above] Column (b) and (c) not requestedfor 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. File this form online: http://www.usac.org/about/tools/e-file.aspxFor additional information regarding this worksheet contact: Telecommunications Reporting Worksheet Info: (888)641-8722 or via email: Form 499@usac.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. 2471001 Save time, avoid problems 226 file electronically at http://forms.universalservice.org FCC Form 499-Q /February 2019 American LegalNet, Inc. www.FormsWorkFlow.com