FCC 505 Connect America Phase II Challenge Process Form

Competitive Carrier Line Count Report and Self-Certification as a Rural Carrier, FCC Forms 481, 507, 508, 509, and 525

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3060-0986 can be found here:

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Connect America Phase II Challenge Process Form
OMB Control Number 3060-0986
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:

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 3060-0986

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 3060-0986

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 3060-0986

OMB Control Number 3060-0986

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.