569 General Information & Area Coverage Survey (ACS)

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0572-0079. The time required to complete this information collection is estimated to average 4 hours per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

RURAL UTILITIES SERVICE - USDA

NAME OF BORROWER

LOCAL SERVICE DATA FORM
Instructions -

BORROWER DESIGNATION

PART A - AREA COVERAGE DATA - TOTAL SYSTEM
EXISTING

EXCHANGES
Use additional pages if necessary
Exchange

State

County

Access Lines
B1

R1

Other*

Total

B1
$

Total System
Comments:
(*Describe "Other" Access Lines)

RUS Form 569 (Rev. 9-03) Page 1

R1
$

PROPOSED

Access Lines

Rates
B1

R1

Other*

Rates
Total

B1
$

R1
$

RURAL UTILITIES SERVICE - USDA

NAME OF BORROWER

LOCAL SERVICE DATA FORM
Instructions -

BORROWER DESIGNATION

PART B - ADDITIONAL REVENUE PRODUCING SERVICES - TOTAL SYSTEM
(Annual)
CUSTOM CALLING, CLASS FEATURES
Description of Services

Existing
Number

Revenue

Proposed
Number

$

MOBILE TELEPHONE, CELLULAR, PCS
Description of Services

Existing
Number

Revenue

Proposed
Number

$

DIAL-UP INTERNET
Description of Services

Revenue

Proposed
Number

$
BROADBAND SERVICES, WIRED, WIRELESS, VIDEO
Description of Services

Revenue

Proposed
Number

$

OTHER REVENUE PRODUCING SERVICES
Description of Services

Revenue
$

Comments:

RUS Form 569 (Rev. 9-03 ) Page 2

Revenue
$

Existing
Number

Revenue
$

Existing
Number

Revenue
$

Existing
Number

Revenue
$

Proposed
Number

Revenue
$