Area A: Company Identification

A.1

Legal name of Entity

A.2

Name under which the Telecommunications
Service Provider (TSP) carries on business

A.3

List of Related TSPs (provide a separate list if required)

Area B: Contact Information

B.1

Person who completed this form

B.2

Title of position

B.3

Telephone number

B.4

Fax number

B.5

E-mail address

Area C: Reporting Year Information - Send in a Copy
of the Relevant Financial Statements

C.1

Reporting year

C.2

Fiscal year-end

Area D: Calculation of Contribution-Eligible Revenue

D.1.A

Total Operating Revenues Reported in Financial Statements
(from form 101, line 1)

D.1.B

Add: Deductions from revenues

D.1

Total Operating Revenues for Contribution Purposes

Less

D.2

Non-Canadian Revenues (and complete form 602)

D.3

Canadian Non-Telecommunications Revenues
(and complete form 603)

D.4

Canadian Telecommunications Services Revenues (D.1-D.2-D.3)

Less

D.5

Contribution Payments Received

D.6

Inter-carrier Payments (and complete form 604)

D.7

Retail Internet Service Revenues

D.8

Retail Paging Service Revenues

D.9

Terminal Equipment Revenues

D.10

Non-contribution-eligible revenues eliminated
from those bundles to which both contribution-eligible
and non-contribution-eligible revenues are attributed
(and complete form 605)

D.11

Subtotal (D.5+D.6+D.7+D.8+D.9+D.10)

Add

D.12

Contribution-eligible revenues on Package Discounts

D.13

Contribution-Eligible Revenues (D.4-D.11+D.12)

Please use the space provided below to supply any comments, explanations, methodological notes, qualifiers or other important information about the data you have supplied on this form.