569 RUS Local Service Data Form

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number. The valid 01013 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.

Form Approved
0572-0079
Expires 07/31/2013
RURAL UTILITIES SERVICE - USDA

NAME OF BORROWER

LOCAL SERVICE DATA FORM
Instructions -

BORROWER DESIGNATION

PART A - AREA COVERAGE DATA - TOTAL SYSTEM
EXCHANGES

EXISTING

Use additional pages if necessary
Exchange

State

County

PROPOSED

Access Lines
B1

R1

Other*

Total

B1
$

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

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

Access Lines

Rates

R1
$

B1

R1

Other*

Rates

B1

Total
$

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

Description of Services

MOBILE TELEPHONE, CELLULAR,
PCS

Existing
Number

Revenue

Proposed
Number

$

DIAL-UP
INTERNET

Description of Services

Revenue

Proposed
Revenue

Number

$
BROADBAND SERVICES, WIRED, WIRELESS, VIDEO

$

Existing
Number

Description of Services

Revenue

Proposed

OTHER REVENUE PRODUCING SERVICES

Revenue
$

Comments:

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

$

Existing
Number

Revenue

Number

$

Description of Services

Revenue
$

Existing
Number

Revenue
$

$

Proposed
Revenue

Number
$