Form FCC Form 690 FCC Form 690 Mobility Fund Phase I - Section 54.1009 Annual Reproting

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Overview

Form
(050) Carrier Contact Form
(060) Carrier Coverage
(070) Urban Rate Cert
(080)_Tribal Land forms
(090) Network Update
CERTIFICATION-REPORTING CARRIER
CERTIFICATION-AGENT

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Sheet 1: Form

										FCC Form 690
MOBILITY FUND										Approved by OMB
PHASE 1 - §54.1009 ANNUAL REPORTING										OMB 3060-XXXX
DATA COLLECTION FORM										Avg. Burden Estimate per Respondent: 18 Hours
(010)	Study Area Code(s)							(010)
(015)	Study Area Name(s)							(015)
(020)	Program Year							(020)	2012
(030)	Contact Name: Person USAC should contact
	with questions about this data							(040)
(035)	Contact Telephone Number:
	Number of the person identified in Data Line (030)							(045)
(039)	Contact Email:
	Email of the person identified in Data Line (030)							(049)
									(check box when complete)
(040)	Has the information required pursuant to §54.1009 been provided with a 54.313 filing (Y/N)?								(040)
		Attach a description of the documents filed with the §54.313 reporting							(041)
		Cite the Study Area Code for the §54.313 reporting							(042)
		Cite the date of the §54.313 reporting							(043)
(050)	Carrier Contact Form		(has contact info. changed since prior filing? Yes or No)
					(if yes, complete attached worksheet)				(050)
(060)	Coverage and Performance Report					(complete attached worksheet)			(060)
(070)	Urban Rate Comparability Certification			akavelman: unclear what FCC wants to capture here. Flag for discussion. Some overlap with line item 040		(complete attached certification)			(070)
(080)	Tribal Lands Reporting (Y/N)?
			(Does this study area cover tribal lands? Yes or No)
					(if yes, complete attached worksheet)				(080)
(090)	Project Update Information			akavelman: flag to discuss with FCC. Unclear what data they want to collect		(complete attached worksheet)			(090)
(100)	Certifications
		Reporting Carrier Certification				(complete attached certification)			(101)
		Agent Certification				(complete attached certification)			(102)
				akavelman: unclear what FCC wants to capture here. Flag for discussion. Some overlap with line item 040
				akavelman: waiting to hear from Johnnay about her efforts on operating cos.

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Sheet 2: (050) Carrier Contact Form

{ 050} Carrier Contact Form
(010)	Study Area Code							(010)
(015)	Study Area Name							(015)
(020)	Program Year							(020)	2012
(030)	Contact Name: Person USAC should contact with questions about this data							(030)
(035)	Contact Telephone Number:			Number of the person identified in Data Line (030)				(035)
(039)	Contact Email:		Email of the person identified in Data Line (030)					(039)
Reporting Carrier / Mobility Fund Phase 1 Winning Bidder
(110)	FCC Registration Number
(111)	Filing Carrier Name
(112)	Winning Bidder Carrier Name
(113)	Street Address (or PO Box)
(114)	City
(115)	State
(116)	Zip-Code
(117)	Telephone Number
(118)	Fax Number
(119)	Email Address
Contact Information			if same as above, indicate in this box
(120)	Name (First, MI, Last, Suffix)
(121)	Filing Carrier Name
(122)	Street Address (or PO Box)
(123)	City
(124)	State
(125)	Zip-Code
(126)	Telephone Number
(127)	Fax Number
(128)	Email Address
				akavelman: flag to discuss with FCC. Unclear what data they want to collect
Authorized Agent Information				if no agent, indicate in this box
(130)	Name (First, MI, Last, Suffix)
(131)	Company
(132)	Street Address (or PO Box)
(133)	City
(134)	State
(135)	Zip-Code
(136)	Telephone Number
(137)	Fax Number
(138)	Email Address

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Sheet 3: (060) Carrier Coverage

(060) Coverage and Performance Report

<010>

Study Area Code(s)

<010>

_________________

<015>

Study Area Name(s)

<015>

_________________

<020>

Program Year

<020>

_________________

<030>

Contact Name - Person USAC should contact regarding this data

<030>

_________________

<035>

Contact Telephone Number - Number of person identified in data line <030>

<035>

_________________

<039>

Contact Email Address - Email Address of person identified in data line <030>

<039>

_________________

<140>

Coverage and Performance Report Year

<041>

_________________

<141>

<a1>

<a2>

<a3>

<a4>

<b1>

<b2>

<c1>

<c2>

<c3>

<d>

<e>

<f>

Study Area Code

State

County

Census Block

Resident Population per Census Block

Resident Population Newly Reached by Service

Road Miles per Census Block

Road Miles per Census Block Newly Served

Percent Road Miles Covered

Certify Electronic Shapefiles are attached (Yes/No)

Certify: Drive Test Results are attached(Yes/No)

Certify: Scattered Site Test Results are attached (Yes/No)

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Sheet 4: (070) Urban Rate Cert

(070) Certification Compliance with 47 CFR §54.1009(a)(4)

The Reporting Carrier offers service in supported areas at rates that are within a reasonable range of rates for similar service plans offered by mobile wireless providers in urban areas.

TO BE COMPLETED BY THE REPORTING CARRIER, IF THE REPORTING CARRIER IS FILING CERTIFICATION ON ITS OWN BEHALF:

Certification of Officer as to Compliance with 47 CFR §54.1009(a)(4)

I certify that I am an officer or employee of the reporting carrier; my responsibilities include ensuring compliance with 47 CFR §54.1009(a)(4), the information reported on this form is accurate.

Name of Reporting Carrier

Signature of authorized officer

Date

Printed name of authorized officer

Title or position of authorized officer

Telephone number of authorized officer: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _

Study Area Code of Reporting Carrier

Filing Due Date for this form (mm/dd/yyyy)

TO BE COMPLETED BY THE REPORTING CARRIER, IF AN AGENT IS FILING CERTIFICATION DATA ON THE CARRIER'S BEHALF:

Certification of Officer or Employee to Authorize an Agent to File Compliance with 47 CFR §54.1009(a)(4) on Behalf of Reporting Carrier

I certify that (Name of Agent)_______________________________________________________ is authorized to submit the information reported on behalf of the reporting carrier. I also certify that I am an officer or employee of the reporting carrier; my responsibilities include ensuring the compliance with 47 CFR §54.1009(a)(4) as reported to the authorized agent; and, to the best of my knowledge, the certification provided to the authorized agent is accurate.

Name of Authorized Agent

Name of Reporting Carrier

Signature of authorized officer

Date

Printed name of authorized officer

Title or position of authorized officer

Telephone number of authorized officer: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _

Study Area Code of Reporting Carrier

Filing Due Date for this form (mm/dd/yyyy)

TO BE COMPLETED BY THE AUTHORIZED AGENT:

Certification of Agent Authorized to File Compliance with 47 CFR §54.1009(a)(4) on Behalf of Reporting Carrier

I, as agent for the reporting carrier, certify that I am authorized to submit the certification on behalf of the reporting carrier; I have provided the data reported herein based on data provided by the reporting carrier; and, to the best of my knowledge, the information reported herein is accurate.

Name of Reporting Carrier

Name of Authorized Agent

Signature of authorized agent or employee of agent

Date

Printed name of authorized agent or employee of agent

Title or position of authorized agent or employee of agent

Telephone number of authorized agent: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _

Study Area Code of Reporting Carrier

Filing Due Date for this form (mmddyyyy)

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Sheet 5: (080)_Tribal Land forms

(080) Tribal Lands Reporting
<010>	Study Area Code(s)				<010>	_________________
<015>	Study Area Name(s)				<015>	_________________
<020>	Program Year				<020>	_________________
<030>	Contact Name - Person USAC should contact regarding this data				<030>	_________________
<035>	Contact Telephone Number - Number of person identified in data line <030>				<035>	_________________
<039>	Contact Email Address - Email Address of person identified in data line <030>				<039>	_________________
<140>	Coverage and Performance Report Year				<041>	_________________
<142>		<a1>	<a2>	<a3>	<a4>	<a5>
		Study Area Code	State	County	Tribal Lands on which the ETC serves	Tribal Government Engagement Obligation
						{Name of PDF}
						{Name of PDF}
						{Name of PDF}
						{Name of PDF}
						{Name of PDF}

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Sheet 6: (090) Network Update

(090) Project Update Information

<010>

Study Area Code(s)

<010>

_________________

<015>

Study Area Name(s)

<015>

_________________

<020>

Program Year

<020>

_________________

<030>

Contact Name - Person USAC should contact regarding this data

<030>

_________________

<035>

Contact Telephone Number - Number of person identified in data line <030>

<035>

_________________

<039>

Contact Email Address - Email Address of person identified in data line <030>

<039>

_________________

<143>

<a1>

<a2>

<a3>

<b1>

<b2>

<c1>

<c2>

<c3>

<c4>

<c5>

<c6>

<d1>

<d2>

<e>

<f>

Study Area Code

State

County / City

Date Authorized to Receive Support

Targeted Completion Date

Total Mobility Fund Support Awarded

Total Mobility Fund Support Disbursed

Support Applied to Network Design

Support Applied to Construction

Support Applied to Deployment

Support Applied to Maintenance

Certify Network will Support 3G Mobile Service (Yes/No)

Certify Network will Support 4G Mobile Service (Yes/No)

Actual Completion Date

Project Status Description attached (Yes/No)

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Sheet 7: CERTIFICATION-REPORTING CARRIER

TO BE COMPLETED BY THE REPORTING CARRIER, IF THE REPORTING CARRIER IS FILING ANNUAL REPORTING ON ITS OWN BEHALF:

Certification of Officer as to the Accuracy of the Data Reported for the Annual Reporting for Mobility Fund Recipients

I certify that I am an officer of the reporting carrier; my responsibilities include ensuring the accuracy of the annual reporting requirements for Mobility Fund recipients; and, to the best of my knowledge, the information reported on this form is accurate.

Name of Reporting Carrier

Signature of Authorized Officer

Date

Printed name of Authorized Officer

Title or position of Authorized Officer

Telephone number of Authorized Officer: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _

Study Area Code of Reporting Carrier

Filing Due Date for this form (mm/dd/yyyy)

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Sheet 8: CERTIFICATION-AGENT

TO BE COMPLETED BY THE REPORTING CARRIER, IF AN AGENT IS FILING ANNUAL REPORTS ON THE CARRIER'S BEHALF:

Certification of Officer to Authorize an Agent to File Annual Reports for Mobility Fund Recipients on Behalf of Reporting Carrier

I certify that (Name of Agent)_______________________________________________________ is authorized to submit the information reported on behalf of the reporting carrier. I also certify that I am an officer of the reporting carrier; my responsibilities include ensuring the accuracy of the annual data reporting requirements provided to the authorized agent; and, to the best of my knowledge, the reports and data provided to the authorized agent is accurate.

Name of Authorized Agent

Name of Reporting Carrier

Signature of Authorized Officer

Date

Printed name of Authorized Officer

Title or position of Authorized Officer

Telephone number of Authorized Officer: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _

Study Area Code of Reporting Carrier

Filing Due Date for this form (mm/dd/yyyy)

TO BE COMPLETED BY THE AUTHORIZED AGENT:

Certification of Agent Authorized to File Annual Reports for Mobility Fund Recipients on Behalf of Reporting Carrier

I, as agent for the reporting carrier, certify that I am authorized to submit the annual reports for Mobility Fund recipients on behalf of the reporting carrier; I have provided the data reported herein based on data provided by the reporting carrier; and, to the best of my knowledge, the information reported herein is accurate.

Name of Reporting Carrier

Name of Authorized Agent or Employee of Agent

Signature of Authorized Agent or Employee of Agent

Date

Printed name of Authorized Agent or Employee of Agent

Title or position of Authorized Agent or Employee of Agent

Telephone number of Authorized Agent or Employee of Agent: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _

Study Area Code of Reporting Carrier

Filing Due Date for this form (mmddyyyy)