FCC 509 Annual Common Line Actual Cost Data Collection

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

Copy of 509 Form.xls

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

OMB: 3060-0986

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Overview

ANN. COMMON LINE COSTS
509 CERT.-REPORTING CARRIER
509 CERTIFICATION-AGENT
509 NOTICE


Sheet 1: ANN. COMMON LINE COSTS

ANNUAL COMMON LINE ACTUAL COST DATA COLLECTION
Block 1 - Contact Information
ROW # DATA ELEMENT FORMAT OF REQUESTED DATA RESPONSE
1 Carrier Study Area Code 6 numeric digits
2 Carrier Study Area Name alpha characters
3 Service Provider Identification Number 9 numeric digits
4 Data Period (specify years) mm/dd/yyyy - mm/dd/yyyy
5 Date of Submission mm/dd/yyyy
6 Contact Name alpha characters
7 Contact Telephone Number [including area code] 10 numeric digits
8 Contact E-mail Address alpha/numeric characters
Block 2 - Actual Annual Common Line Revenue Requirement by Study Area
9 Annual Common Line Costs for the reporting period amount in $
10 Annual SLC Revenues for the reporting period amount in $
11 Annual Special Access Surcharges for the reporting period amount in $
12 Annual Line Port Costs in Excess of Basic Analog Service for the reporting period amount in $
13 Annual LTS for the reporting period amount in $
14 Annual Transitional Carrier Common Line Charge Revenues for the reporting period amount in $

Sheet 2: 509 CERT.-REPORTING CARRIER

TO BE COMPLETED BY THE REPORTING CARRIER, IF THE REPORTING CARRIER IS FILING FCC FORM 509 ON ITS OWN BEHALF:


























































Certification of Officer or Employee as to the Accuracy of the Data Reported in FCC Form 509, Interstate Common Line Support Mechanism Annual Common Line Actual Cost Data Collection Form, on Behalf of Reporting Carrier














































Name of Reporting Carrier
Signature of authorized officer or employee Date
Printed name of authorized officer or employee
Title or position of authorized officer or employee
Telephone number of authorized officer or employee: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _
Study Area Code of Reporting Carrier

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





Sheet 3: 509 CERTIFICATION-AGENT

TO BE COMPLETED BY THE REPORTING CARRIER, IF AN AGENT IS FILING FCC FORM 509 ON THE CARRIER'S BEHALF:













































Certification of Officer or Employee to Authorize an Agent to File FCC Form 509, Interstate Common Line Support Mechanism Annual Common Line Actual Cost Data Collection Form, on Behalf of Reporting Carrier

















Name of Authorized Agent
Name of Reporting Carrier
Signature of authorized officer or employee Date
Printed name of authorized officer or employee
Title or position of authorized officer or employee
Telephone number of authorized officer or employee: ( _ _ _ ) _ _ _ - _ _ _ _, 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 FCC Form 509, Interstate Common Line Support Annual Common Line Actual Cost Data Collection Form, on Behalf of Reporting Carrier































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 (mm/dd/yyyy)



Sheet 4: 509 NOTICE















File Typeapplication/vnd.ms-excel
File TitleICLS Year 2 Form 508
SubjectOTHR
Last Modified ByNicole Ongele
File Modified2016-04-25
File Created2002-05-06

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