FCC Form 497, Lifeline and Linkup Worksheet

FCC Form 497

LIFELINE AND LINK UP WORKSHEET

Approved by OMB

July 2008 Edition

3060-0819

Avg. Burden Est. per Respondent: 3.0 Hrs.

USAC Service Provider Identification Number (1)

Serving Area (2)

(3)

(4)

Company Name:

Mailing Address:

a) Submission Date

b) Data Month

Contact Name:

Telephone Number:

c) Type of filing (Check one):

Original q

Revision q

Fax Number:

E-mail Address:

d) State Reporting

Lifeline

# Lifeline

Lifeline Support/

Total Lifeline

Subscribers

Subscriber

Support

Tier 1 Low-Income Subscribers

(a)

(b)*

(c)

receiving federal Lifeline Support

(5)

____________

x

$

____________

=

$

Tier 2 Low-Income Subscribers

receiving federal Lifeline Support

(6)

____________

x

$

____________

=

$

Tier 3 Low-Income Subscribers

receiving federal Lifeline Support

(7)

____________

x

$

____________

=

$

Tier 4 Low-Income Subscribers

receiving federal Lifeline Support

(8)

____________

x

$

____________

=

$

Check box to the right if partials or pro rata amounts are used. Indicate dollar amount, if applicable, on line 9.

q

$

(9)

NOTE: (Do not include partials or pro rata amounts on lines 5 - 8 above)

Total federal Lifeline support claimed

$

(10)

* For multiple rates, use an average amount

(Sum of lines 5c, 6c, 7c, 8c & 9)

Link Up

Non-Tribal

Tribal

Total Link Up

(a)

(b)

(c)

Number of Connections waived

(11)

____________

____________

Charges waived per Connection

(12)

*

$____________

($30 max)

$____________

($100 max)

Total Connection charges waived

(13)

$____________

$____________

Deferred Interest

(14)

$____________

$____________

Total Link Up dollars waived

(15)

$____________

+

$____________

=

$

(15c)

* For multiple rates, use an average amount

Toll-Limitation Services (TLS)

Incremental cost of providing TLS

(16)

$__________

Number of subscribers for whom

(17)

__________

Total TLS dollars claimed

$

(18)

TLS initiated

ETC Payment (19)

Total Lifeline

$

Total TLS

$

Total Link Up

$

Total Dollars

$

If you have any questions, please call USAC at (866) 873(USF)-4727 Toll Free

FCC Form 497

LIFELINE AND LINK UP WORKSHEET

Approved by OMB

July 2008 Edition

3060-0819

Avg. Burden Est. per Respondent: 3.0 Hrs.

CERTIFICATIONS AND SIGNATURES (20)

I certify that my company will publicize the availability of Lifeline and Linkup services in a manner reasonably designed to reach those likely to qualify

for those services.

I certify that my company will pass through the full amount of all Tier Two, Tier Three, and Tier Four federal Lifeline support for which my company

seeks reimbursement, as well as all applicable intrastate Lifeline support, to all qualifying low-income subscribers by an equivalent reduction in the

subscriber's monthly bill for local telephone service.

I certify that my company has received any non-federal regulatory approvals necessary to implement the required rate reduction(s).

I certify that my company is _____ is not _____ subject to state regulation. (Please check one.)

Based on the information known to me or provided to me by employees responsible for the preparation of the data being submitted, I certify that the

data contained in this form has been examined and reviewed and is true, accurate, and complete.

I acknowledge the Fund Administrator's authority to request additional supporting information as may be necessary.

DATE

OFFICER/EMPLOYEE SIGNATURE

OFFICER/EMPLOYEE TITLE

OFFICER/EMPLOYEE NAME

NOTICE: To implement Section 254 of the Communications Act of 1934, as amended, the Federal Communications Commission has adopted changes to the federal low-income programs.

The Commission has expanded the availability of these programs and the level of funding for discounts to low-income customers.

The following worksheet provides the means by which eligible telecommunications carriers will be reimbursed by the Universal Service Administrative Company (USAC) for their participation

in these programs. Failing to collect the information, or collecting it less frequently, would prevent the Commission from implementing sections 214 and 254 of the Act, would thwart Congress'

goals of providing affordable service and access to advanced services throughout the nation, and would result in eligible telecommunications carriers not receiving universal service support

reimbursements in a timely fashion.

We have estimated that each response to this collection of information will take, on average, three hours for each respondent. Our estimate includes the time to read this data request,

review existing records, gather and maintain required data, and complete and review the response. If you have any comments on this estimate, or on how we can improve the

collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Washington, D.C. 20554, Paperwork Reduction Project (3060-0819).

We will also accept your comments on the burden estimate via the Internet if you send them to [email protected]. Please DO NOT SEND the data requested to this e-mail address.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

The FCC is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. If we believe there may be a violation or a potential violation of

a FCC statute, regulation, rule or order, your worksheet may be referred to the Federal, state or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute,

rule, regulation or order. In certain cases, the information in your worksheets may be disclosed to the Department of Justice or a court or adjudicative body when (a) the FCC; or (b) any employee

of the FCC; or (c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding.

If you do not provide the information we request on the form, the FCC may delay processing of your worksheet or may return your worksheet without action.

The foregoing Notice is required by the Privacy Act of 1974, Pub. L. No. 93-579, December 31, 1974, 5 U.S.C. Section 552, and the Paperwork Reduction Act of 1995, Pub. L. No. 104-13,

44 U.S.C. Section 3501, et seq.

FCC Form 497 Instructions

Instructions For

Approved by OMB

July 2008 Edition

LIFELINE and LINK UP WORKSHEET

3060-0819

Avg. Burden Est. per Respondent: 3.0 Hrs.

Pursuant to Section 54.405, all eligible telecommunications carriers (ETCs) are required to provide Lifeline service. In turn, these ETCs are

permitted under Section 54.407 (Lifeline) or Section 54.413 (Link Up) to receive support for offering Lifeline service to qualifying low-income

customers or reduced service-connection charges through Link Up. Pursuant to Section 54.403(c), carriers providing toll-limitation services (TLS)

for qualifying low-income subscribers will be compensated from universal service mechanisms for the incremental cost of providing TLS.

FCC Form 497 is to be used to request reimbursement for participating in the low-income program.

Line 1

USAC Service Provider Identification Number (SPIN) - Please enter your 9-digit USAC Service

Provider Identification Number.

Line 2

Serving Area - Indicate the 6-digit serving area for which you are claiming reimbursement.

Box 3

Company Name, Mailing Address - Indicate your company name and mailing address.

Contact Name,Telephone Number and Fax Number - Person who should be contacted

in the event we have inquiries regarding your form.

E-mail Address - Indicate e-mail address of contact person listed above.

Box 4

a) Submission Date - The date that you are filling out this form.

b) Data Month - The month for which you are reporting data. Please submit one

worksheet per month, on a quarterly basis.

c) Type of filing - Check "original" box if your company is reporting this data for the

first time. If this is a revision to the data originally submitted, check the "revision" box.

Revisions will not be accepted later than 12 months after the data month for which

the revision applies. Report originals and revisions on separate forms. For revisions,

all line items should be reported as positive numbers reflecting the actual amounts that

should have been claimed for the month.

d) State Reporting - Please indicate in what state you are reporting activity.

Lifeline:

Description:

The federal Lifeline Program benefits eligible low-income subscribers by reducing their monthly local phone charge by up to $10.00 per month. In addition, enhanced or tribal customers may receive a reduction of up to $35.00 in their monthly local phone charge.

Tier 1

All eligible subscribers will receive up to $6.50 in federal support which is equal to the tariffed rate in effect for the primary residential End User Common Line charge of the incumbent local exchange carrier serving the area in which the qualifying low-income consumer receives service.

Tier 2

Another $1.75 of federal support is available if the carrier certifies that it will pass through the

full amount of Tier 2 support to its qualifying, low-income consumers and has received any

non-federal regulatory approvals necessary to implement the required rate reduction.

Tier 3

Additional federal Lifeline support in an amount equal to one-half the amount of any state-

mandated Lifeline support, or Lifeline support provided by the carrier, up to a maximum of

$1.75 per month, is also available, provided that the carrier has received any non-federal

regulatory approvals and will pass through the full amount of Tier 3 support to its qualifying

low-income consumers.

Tier 4

Additional federal Lifeline support of up to $25 per month is available to eligible residents of

tribal lands, as defined in 47 C.F.R. section 54.400(e), as long as that amount does not bring

the basic local residential rate below $1 per month per qualifying low income subscriber.

Line 5(a)

Provide the monthly number of low-income subscribers, for whom Tier 1 federal support is claimed.

Line 5(b)

Enter the rate of baseline federal support claimed per subscriber. All eligible subscribers will receive an amount equal to the End User Common Line charge in effect for the incumbent local exchange carrier.

Line 5(c)

Enter the total dollar amount of Tier 1 Lifeline support claimed. The amount will equal the

product of line 5(a) and line 5(b). Amount should be reported in whole dollars.

FCC Form 497 Instructions

Instructions For

Approved by OMB

July 2008 Edition

LIFELINE and LINK UP WORKSHEET

3060-0819

Avg. Burden Est. per Respondent: 3.0 Hrs.

Line 6(a)

Provide the monthly count of low-income subscribers, for whom Tier 2 federal support

is claimed.

Line 6(b)

Enter the additional rate per subscriber ($1.75) for Tier 2 federal Lifeline support (if applicable).

Line 6(c)

Enter the total dollar amount of Tier 2 Lifeline support claimed. This amount is the

product of line 6(a) and line 6(b). Amount should be reported in whole dollars.

Line 7(a)

Provide the monthly count of low-income subscribers, for whom Tier 3 federal Lifeline support

is claimed.

Line 7(b)

Enter the rate per subscriber for Tier 3 federal Lifeline support claimed ( if applicable). This

amount should be between $0 (no state support) and $1.75 (maximum federal support allowed).

Line 7(c)

Enter the total dollar amount of Tier 3 Lifeline support claimed. This amount is the

product of line 7(a) and line 7(b). Amount should be reported in whole dollars.

Line 8(a)

Provide the monthly count of low-income subscribers, for whom Tier 4 federal Lifeline support

is claimed.

Line 8(b)

Enter the rate per subscriber for Tier 4 Lifeline support claimed. This can range from $0

to a maximum of $25.

Line 8(c)

Enter total dollar amount of Tier 4 Lifeline support claimed. The amount will equal the

product of line 8(a) and line 8(b). Amount should be reported in whole dollars.

Line 9

If claiming partial or pro-rata dollars, check the box on line 9.

Enter the dollar amount (if applicable) for all partial or pro-rated subscribers. Amount should be

reported in whole dollars, and may be either positive or negative, depending on whether there are

more new subscribers being added part way through a month or more subscribers disconnecting

during the reported month. DO NOT include partial or pro-rata amounts on lines 5 - 8.

Line 10

Total Lifeline dollars claimed for the reported month. Should be equal to the sum of lines 5(c), 6(c),

7(c), 8(c) and 9 and reported in whole dollars.

Link Up:

Description: Link Up reduces eligible low-income subscribers' charges for starting telephone service

by one-half of the telephone company's charge, or $30.00, whichever is less, for subscribers residing on

non-tribal lands. For subscribers residing on tribal lands, the reduction is up to $100.

Link Up also offers a deferred payment plan for charges assessed for starting service, for which eligible

subscribers do not have to pay interest. Eligible subscribers are relieved of the requirement to pay

interest charges of up to $200 for a period not to exceed one year.

(a) Non-Tribal Land Low-Income Subscribers Only

Line 11(a)

Provide the monthly count of Link Up subscribers not residing on tribal lands for whom connection

charges are waived.

Line 12(a)

Enter the dollar amount of reduction per subscriber. The reduction should be one-half of the

service providers' charge or $30.00, whichever is less. For multiple rates, use an averaged amount.

Line 13(a)

Enter the dollar amount of connection charges reduced (multiply Lines 11(a) and 12(a)).

Line 14(a)

Enter the dollar amount of deferred interest (if applicable).

Line 15(a)

Enter the dollar amount of total Link Up support (sum of Lines 13(a) and 14(a)). All amounts should

be reported in whole dollars.

FCC Form 497 Instructions

Instructions For

Approved by OMB

July 2008 Edition

LIFELINE and LINK UP WORKSHEET

3060-0819

Avg. Burden Est. per Respondent: 3.0 Hrs.

Link Up:

(b) Tribal Land Low-Income Subscribers Only

Line 11(b)

Enter monthly count of Link Up subscribers residing on tribal lands, designated as such by

the Bureau of Indian Affairs, for whom charges are waived.

Line 12(b)

Enter the dollar amount of reduction per subscriber. This reduction should not exceed $100

in total. In addition to the $30.00 referenced in paragraph 12(a) above, an additional $70.00 reduction

is available to cover 100 per cent of the charges between $60.00 and $130.00 for commencing

service at the principal place of residence of an eligible resident of tribal lands.

Line 13(b)

Enter the dollar amount of connection charges reduced (multiply Lines 11(b) and 12(b)).

Line 14(b)

Enter the dollar amount of deferred interest (if applicable).

Line 15(b)

Enter the dollar amount of total Link Up support (sum of Lines 13(b) and 14(b)). All amounts

should be reported in whole dollars.

(c) Total Link Up

(Shaded box)

Line 15(c)

Total Link Up dollars claimed for the reported month. Should be equal to the sum of

lines 15(a) and 15(b) and reported in whole dollars.

Toll Limitation Services (TLS):

Description: TLS is a service that carriers must provide to eligible low-income

subscribers in order to be eligible to receive universal service support. This service

includes toll blocking, which allows subscribers to block outgoing toll calls, and also

toll control, which allows subscribers to limit in advance their toll usage per month or

billing cycle. Carriers are required to provide at least one type of toll-limitation service,

unless their state commission provides them with additional time to complete the

network upgrades needed to provide TLS.

Support will be provided for the incremental cost of providing TLS. These costs include the costs that carriers otherwise would not incur if they did not provide TLS to a given customer. The incremental cost of TLS does not include the full retail charge for TLS that the carrier would charge other consumers. Moreover, joint and common costs associated with TLS are not supported by the Low Income support mechanism. In addition, Lifeline support in excess of the incremental cost of providing toll blocking will not be provided for switch upgrades.

Line 16

Enter the dollar amount for the incremental cost of providing TLS. Carriers may be asked for supporting documentation justifying the incremental costs of providing TLS claimed on this Worksheet.

Line 17

Enter number of eligible subscribers for whom TLS was initiated.

Must be equal to or less than either the number of Lifeline low income subscribers

or Link Up low income subscribers.

Line 18

Enter the dollar amount of total TLS dollars claimed (multiply Lines 16 and 17).

All amounts should be reported in whole dollars.

Box 19

This is the Total Low-Income Support amount to be paid to Eligible Telecommunications Carriers

for the reported month. Enter the dollar amounts from Lines 10 - total Lifeline, 15(c) - total Link Up and

18 - total TLS. Enter the sum of these dollars on the line labelled Total Dollars.

All amounts should be reported in whole dollars.

USAC projects each month's payment prior to receiving actual data and, upon receipt of actual data

submitted on FCC Form 497, trues up the total dollars.

FCC Form 497 Instructions

Instructions For

Approved by OMB

July 2008 Edition

LIFELINE and LINK UP WORKSHEET

3060-0819

Avg. Burden Est. per Respondent: 3.0 Hrs.

Certifications and Signatures (Block 20)

Page 2 of FCC Form 497 requires the signature of an officer or employee of the company

certifying that the following statements are correct (as applicable):

1) Certify that your company will publicize the availability of Lifeline and Link Up

services in a manner reasonably designed to reach those likely to qualify for those services.

See 47 C.F.R. Section 54.405(b).

2) Certify that your company will pass through the full amount of all Tier Two, Tier Three,

and Tier Four federal Lifeline support for which they seek reimbursement, as well as all

applicable intrastate Lifeline support, to all qualifying low-income subscribers by an equivalent

reduction in the subscriber's monthly bill for local telephone service. See 47 C.F.R.

sections 54.403(a),(2), (3) and (4).

3) Certify that your company has received any non-federal regulatory approvals necessary

to implement the required rate reduction(s). See Federal-State Joint Board on Universal

Service: Promoting Deployment and Subscribership in Unserved and Underserved Areas,

Including Tribal and Insular Areas, CC Docket No. 96-45, Twelfth Report and Order, Memorandum

Opinion and Order, and Further Notice of Proposed Rulemaking, FCC 00-208 (rel. June 30, 2000),

at paras. 43 and 85 (Tribal Order).

4) Certify (check off only one) whether or not your company is subject to state regulation.

See Tribal Order at paras. 85 and 89.

5) Certify that the data contained in this form has been examined and reviewed and is true,

accurate, and complete.

Completed worksheet and certification should be returned to the USAC Piscataway office listed below by the third

Monday after the end of each quarter. (See schedule listed below). You should submit three separate worksheets

per quarter, i.e., one worksheet for each month within the quarter.

Due Dates of Forms

Data Months

Sent to USAC Piscataway Office

January

February

3rd Monday in April

March

April

May

3rd Monday in July

June

July

August

3rd Monday in October

September

October

November

3rd Monday in January

December

FCC Form 497 Instructions

Instructions For

Approved by OMB

July 2008 Edition

LIFELINE and LINK UP WORKSHEET

3060-0819

Avg. Burden Est. per Respondent: 3.0 Hrs.

Forms can be faxed to the USAC Piscataway office at (866) 873(USF)-4665 Toll Free

(Attention: Low Income Program) or mailed to:

USAC - Low Income Program

444 Hoes Lane

RR 4A1060

Piscataway, NJ 08854

NOTICE: To implement Section 254 of the Communications Act of 1934, as amended, the Federal Communications Commission has adopted changes to the federal low-income programs.

The Commission has expanded the availability of these programs and the level of funding for discounts to low-income customers.

The following worksheet provides the means by which eligible telecommunications carriers will be reimbursed by the Universal Service Administrative Company (USAC) for their participation

in these programs. Failing to collect the information, or collecting it less frequently, would prevent the Commission from implementing sections 214 and 254 of the Act, would thwart Congress'

goals of providing affordable service and access to advanced services throughout the nation, and would result in eligible telecommunications carriers not receiving universal service support

reimbursements in a timely fashion.

We have estimated that each response to this collection of information will take, on average, three hours for each respondent. Our estimate includes the time to read this data request,

review existing records, gather and maintain required data, and complete and review the response. If you have any comments on this estimate, or on how we can improve the

collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Washington, D.C. 20554, Paperwork Reduction Project (3060-0819).

We will also accept your comments on the burden estimate via the Internet if you send them to [email protected]. Please DO NOT SEND the data requested to this e-mail address.

Remember -- An agency may not conduct or sponsor, and a person is not required to respond to a collection of information sponsored by the Federal government unless it

displays a currently valid OMB control number. This information collection has been assigned OMB Control Number: 3060-0819.

The FCC is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. If we believe there may be a violation or a potential violation of

a FCC statute, regulation, rule or order, your worksheet may be referred to the Federal, state or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute,

rule, regulation or order. In certain cases, the information in your worksheets may be disclosed to the Department of Justice or a court or adjudicative body when (a) the FCC; or (b) any employee

of the FCC; or (c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding.

If you do not provide the information we request on the form, the FCC may delay processing of your worksheet or may return your worksheet without action.

The foregoing Notice is required by the Privacy Act of 1974, Pub. L. No. 93-579, December 31, 1974, 5 U.S.C. Section 552, and the Paperwork Reduction Act of 1995, Pub. L. No. 104-13,

44 U.S.C. Section 3501, et seq.