FCC Form 550 Approved by OMB
November 2012 3060-0819
Ave. Burden Estimate per Respondent: 2.5 hours
LOW INCOME BROADBAND PILOT PROGRAM REIMBURSEMENT FORM
S
F
S
L
E
H
C
C
C
C
S
D
Month of Project of
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S
T
F
Stand Alone Broadband
Both
If offering voice and broadband bundled service, do not claim Lifeline reimbursement on FCC Form 497 for the same subscribers.
Recurring Charges: A. Number of Subscribers X B. rate
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Optional – Use line 19 (and 20-21, if necessary) if providing discounted broadband service at multiple rates to consumers as part of the Low Income Broadband Pilot Program.
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= C. support claimed
Optional – Use line 22 (and 23-24, if necessary) if providing discounted broadband service with varying levels of non-recurring charges to consumers as part of the Low Income Broadband Pilot Program.
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=
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Total Reimbursement Claimed (recurring and non-recurring)
26. Attach list of unique subscriber identifying numbers. Include each subscriber for which ETC seeks reimbursement (data may be submitted in Excel or CSV).
Certification and Signature
I certify that my company has provided the support claimed on this form to qualifying subscribers by an equivalent reduction in the subscriber’s monthly bill for broadband service.
I certify that my company is in compliance with the requirements of the FCC’s Broadband Pilot Program, including reporting requirements and filing deadlines.
I certify that the data contained on this form has been examined and reviewed and is true, accurate and complete.
Persons willfully making false statements on this form can be punished by fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. §1001.
Date Officer Signature
Officer Title Officer Name
Instructions for
LOW INCOME BROADBAND PILOT PROGRAM REIMBURSEMENT FORM
Line 1 Enter the company’s nine-digit USAC-assigned Service Provider Identification Number (SPIN).
Line 2 Enter the company’s 499 Filer ID. This code is assigned by the FCC’s Data Collection Agent after the company files its first FCC Form 499-A.
Line 3 Enter the company’s six-digit Study Area Code (SAC).
Line 4 Enter the USAC-assigned Low Income Broadband Pilot Program Number.
Line 5 Enter the name of the eligible telecommunications carrier (ETC) claiming support on this form.
Line 6 Enter the name of the holding company of the ETC claiming support on this form.
Line 7 Enter the company’s mailing address.
Line 8 Enter the company’s telephone number.
Line 9 Enter the company’s fax number.
Line 10 Enter the e-mail address for an employee of the company who can answer questions about this submission.
Line 11 Enter the date this form is submitted.
Line 12 Enter the month during which the company has provided the discounted broadband service for which it is claiming reimbursement.
Line 13 Each Low Income Broadband Pilot Program has been approved for a particular duration. Indicate which month, out of the total number of months of the broadband pilot program, the support claim covers (for example, “month 5 of 12”). The total number of months should not exceed the length of the pilot program approved for the company.
Line 14 Check “original” if your company is reporting this data for the first time. Check “revision” if your company is revising a previously submitted Low Income Broadband Pilot Program Reimbursement Form.
Line 15 Indicate which state the company provided the service for which it seeks reimbursement.
Line 16 Indicate whether the service was provided to residents of tribal or non-tribal lands.
Line 17 Indicate whether the technology used to provide broadband is fixed or mobile.
Line 18 Indicate whether the service provided was part of a bundled service offering that included both discounted broadband service and voice telephony service. If the service offering is bundled, the company may include reimbursement for the Lifeline discount provided to qualifying customers along with reimbursement for discounted broadband service as part of the Low Income Broadband Pilot Program. If the Lifeline reimbursement is included on this form, do not also include subscribers receiving bundled service on the company’s FCC Form 497. If discounted broadband service is offered as a stand-alone service, the company may claim Lifeline support reimbursement for customers who receive both Lifeline and broadband-discounted service separately (i.e., on this form and on FCC Form 497).
Line 19A Provide the number of subscribers that received discounted broadband service during the month.
Line 19B Provide the recurring (monthly) amount claimed for providing discounted broadband service to the customers reported on Line 19A.
Line 19C Enter the product of lines 19A and 19B. Amount should be reported in whole dollars.
Lines 20-21 If the company is providing discounted broadband service at different recurring (monthly) rates as a condition of its participation in the Low Income Broadband Pilot Program, use lines 20-21 to report the number of subscribers served at each rate.
Line 22A Provide the number of subscribers that received discounted broadband service during the month.
Line 22B Provide the non-recurring (one-time) amount claimed for providing discounted broadband service to the customers reported on Line 22A.
Line 22C Enter the product of lines 22A and 22B. Amount should be reported in whole dollars.
Lines 23-24 If the company is claiming support for different non-recurring (one-time) rates as a condition of its participation in the Low Income Broadband Pilot Program, use lines 23-24 to report the number of subscribers served at each rate.
Line 25 Provide the total amount of support claims (recurring and non-recurring). This amount should equal the sum of lines 19C (and 20C and 21C, if applicable) and 22C (and 23C and 24C, if applicable).
Line 26 Provide a list of unique subscriber identifying numbers. Include each subscriber for which the ETC seeks reimbursement (data may be submitted in Excel or CSV).
Certification Provide the signature, date, name and title of a company officer who can complete the certification.
PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS
The FCC is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. If we believe there may be a violation or a potential violation of a FCC statute, regulation, rule or order, your certification may be referred to the Federal, state or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order. In certain cases, the information in your certification may be disclosed to the Department of Justice or a court or adjudicative body when a) the FCC; or b) any employee of the FCC; or c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding.
We have estimated that this collection of information will take 2.5 hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain required data, and actually complete and review the form or 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, Office of Managing Director, AMD‑PERM, Washington, DC 20554, Paperwork Reduction Act Project (3060‑0819). We will also accept your PRA comments if you send an e-mail to [email protected].
Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. 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 displays a currently valid OMB control number and/or we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060‑0819.
THIS NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. SECTION 552a(e)(3) AND THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.
| File Type | application/msword |
| File Title | FCC Form *** |
| Author | pgallant |
| Last Modified By | judith |
| File Modified | 2012-09-04 |
| File Created | 2012-09-04 |