Annual Lifeline Certification & Verification Letter

Pending OMB Approval

3060-0819

D R A F T

Annual Lifeline Certification & Verification

Complete Section 1, 2, or 3. Then complete the chart below.

1. Eligible Telecommunications Carrier (ETC) serving Federal Default State (complete columns A through E and sign below)

I certify that the company listed below has procedures in place to verify the continued eligibility of a statistically valid random sample of its Lifeline customers. Results are provided in the chart below. I certify that the company listed below has procedures in place to review income documentation and that, to the best of my knowledge, the company was presented with documentation of the consumer’s household income. I am an officer of the company named below. I am authorized to make this certification for the Study Area(s) listed below.

OR

2. Eligible Telecommunications Carrier (ETC) serving Non-Federal Default State (complete columns A through C and sign below; complete columns D and E if required by your state commission)

I certify that the company listed below is in compliance with the Lifeline and Link Up verification procedures in place in the state(s) listed below. If any Lifeline customers of the company listed below qualify based on income, I certify that the company listed below is in compliance with state Lifeline income certification procedures and that, to the best of my knowledge, documentation of income was presented. I am an officer of the company named below. I am authorized to make this certification for the Study Area(s) listed below.

OR

3. I certify that my company has not claimed federal Low Income support for any Lifeline customers in _____ (insert current year).

A	B	C	D	E
Company Name	SAC (6 digit number)	State	Customers Surveyed or Verified	Customers Found to be Ineligible*
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     

* Include customers who did not respond to the survey in the ineligible column.

Signed,

     

(Signature of Officer)

     

(Printed Name of Officer)

     

(Title of Officer)

     

(Person Completing this Sample Letter)

     

(Contact Phone Number)

     

     

(Company Address)

     

(Date)

Submit to USAC using only ONE method:

Fax to: (202) 776-0080

E-mail to: [email protected]

Mail to: Low Income Program

2000 L Street, NW, Suite 200

Washington, DC 20036

Deadline: August 31st

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 a means by which eligible telecommunications carriers may [provide their annual Lifeline verification survey results and annual low-income certifications to the Universal Service Administrative Company.]

We have estimated that each response to this collection of information will take, on average, four (4) 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 – You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it has been approved by the Office of Management and Budget (OMB) and displays a currently valid OMB Control Number. This 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.

The foregoing Notice is required by the Paperwork Reduction Act of 1995, Pub. L. No. 104-13, 44 U.S.C. Section 3501,

et seq.

July 2008 Edition