FCC Form 505 Connect America Phase II Challenge Process Form

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Overview

CoverPage
Served_to_Unserved
Unserved_to_Served
Response_to_Challenge
Certifications_and_Addl_Info

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Sheet 1: CoverPage

Connect America Phase II Challenge Process Form
OMB Control Number [[###]]
FCC Form 505
Filing Entity:
FRN (if applicable):
Name of Person Filling Out Form:
Mailing Address of Person Filling Out Form:
Email Address of Person Filling Out Form:
Phone Number of Person Filling Out Form:
Name of Person Certifying Data within Form:
Mailing Address of Person Certifying Data within Form:
Email Address of Person Certifying Data within Form:
Phone Number of Person Certifying Data within Form:

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Sheet 2: Served_to_Unserved

Census Block 15 Digit FIPS Code	State	Provider Name As Listed in National Broadband Map	Insert X if Speed Criteria Not Met	Insert X if Usage Allowance Criteria Not Met	Insert X if Latency Criteria Not Met	Insert X if Price Criteria Not Met	Insert X if Voice Criteria Not Met	Type of Supporting Evidence	Additional Comments	OMB Control Number [[###]]

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Sheet 3: Unserved_to_Served

Census Block 15 Digit FIPS Code	State	Name of Entity Providing Service	FRN used to File Form 477 (if challenge being filed by the service provider)	Insert an X if you certify that this census block is served by unsubsidized broadband and voice services meeting the Commission's performance and pricing criteria.	Type of Supporting Evidence	Additional Comments	OMB Control Number [[###]]

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Sheet 4: Response_to_Challenge

Census Block 15 Digit FIPS Code	State	Name of Entity Making Initial Challenge	FRN of Entity Making Initial Challenge (if provided)	Insert X if Speed Criteria is at Issue	Insert X if Usage Allowance Criteria is at Issue	Insert X if Latency Criteria is at Issue	Insert X if Price Criteria is at Issue	Insert X if Voice Criteria is at Issue	Type of Supporting Evidence	Additional Comments	OMB Control Number [[###]]

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Sheet 5: Certifications_and_Addl_Info

Accuracy and Due Diligence Certification
All Filers Must Fill Out
By initialing below, I certify that all statements contained in the attached form are true and accurate to the best of my knowledge, and that I have undertaken due diligence to obtain knowledge regarding these claims.
Certifier's Initials:
Date:
Notice of Challenge Certification
(Served to Unserved and Unserved to Served Challengers Fill Out One of the Following Blocks - Respondents Do Not Fill Out)
Service of Notice Successful
By initialing below, I certify that notice of this challenge has been served on all interested parties.
Certifier's Initials:
Date:
Service of Notice Unsuccessful
By initialing below I certify that, following a good faith effort, I was unable to serve notice of this challenge on all interested parties due to lack of information regarding the address of such parties.
Name of Party/Parties that Could Not Be Served:
Certifier's Initials:
Date:
The certifications on this page are subject to the penalties for false statements under 18 U.S.C. 1001.