Form 497 Lifeline Worksheet

FCC Form 497 LIFELINE WORKSHEET OMB Approval

July 2016 Edition 3060-0819

Avg. Burden Est. per Respondent: 2.5 Hrs.

Important: Please Read Instructions First

(1) USAC Service Provider Identification Number _________________________ (2) Study Area Code ____________

(3) Organization Information (4) Filing Information

Company Legal Name:		a) Submission Date		b) Data Month
Contact Name:
Mailing Address:		Type of Filing (check one) Original Revision
		State Reporting
Telephone Number:
Fax Number:
E-mail Address:

Lifeline

Non-Tribal - Receiving Federal Lifeline Support

(a) # Lifeline (b) Lifeline Support/ (c) Total Lifeline

Subscribers Subscriber Support

Voice (5) x $ 9.25 = $

Broadband (6) x $ 9.25 = $

Bundled (7) x $ 9.25 = $

Total Federal Non - Tribal Lifeline Support Claimed (8) $

Tribal - Receiving Federal Lifeline Support (a) # Lifeline (b) Lifeline Support/ (c) Total Lifeline

Subscribers Subscriber Support

Voice (9) x $ = $

Broadband (10) x $ = $

Bundled (11) x $ = $

(not to exceed $34.25 for any subscriber)

Total Federal Tribal Lifeline Support Claimed (12) $

Total Federal Lifeline Support Claimed (13) $

Tribal Link Up (Available only to ETCs receiving High Cost support)

Number of Connections Waived (14) $

Charges Waived per Connection (15) $ (for multiple rates, use an average amount, may not exceed $100)

Total Connection Charges Waived (16) $

Total Tribal Link Up Support Claimed (17) $

Lifeline Provider Payment

Total Lifeline $ Total Tribal Link Up $ Total Dollars (18) $

If you have any questions, please call USAC at (888) 641-8722 Toll Free

(19) CERTIFICATIONS AND SIGNATURES

I certify that my company will pass through the full amount of all Non-Tribal and Tribal federal Lifeline support for which it seeks reimbursement, as well as all applicable intrastate Lifeline support, to all qualifying low-income subscribers by an equivalent reduction in the subscriber's monthly bill for supported service, or by offering a pre-paid wireless plan that complies with the appropriate minimum service standards contained in 47 CFR §54.408.

I certify that my company is in compliance with all of the Lifeline program rules, and, to the extent required, have obtained valid certifications for each subscriber for whom my company seeks reimbursement.

Based on the information known to me or provided to me by employees responsible for the preparation of the data being submitted, I certify under penalty of perjury that the data contained in this form has been examined and reviewed and is true, accurate, and complete.

I acknowledge the Fund Administrator's authority to request additional supporting information as may be necessary.

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

NOTICE: To implement section 254 of the Communications Act of 1934, as amended, the Federal Communications Commission has adopted changes to the federal low-income programs.

The following worksheet provides the means by which eligible telecommunications carriers will be reimbursed by the Universal Service Administrative Company (USAC) for their participation in these programs. Failing to collect the information, or collecting it less frequently, would prevent the Commission from implementing sections 214 and 254 of the Act, would thwart Congress' goals of providing affordable service and access to advanced services throughout the nation, and would result in eligible telecommunications carriers not receiving universal service support reimbursements in a timely fashion.

We have estimated that each response to this collection of information will take, on average, two and one half hours for each respondent. Our estimate includes the time to read this data request, review existing records, gather and maintain required data, and complete and review the 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, AMD-PERM, Washington, D.C. 20554, Paperwork Reduction Project (3060-0819). We will also accept your comments on the burden estimate via the Internet if you send them to [email protected]. Please DO NOT SEND the data requested to this e-mail address.

Remember -- An agency may not conduct or sponsor, and a person is not required to respond to a collection of information sponsored by the Federal government unless it displays a currently valid OMB control number. This information collection has been assigned OMB Control Number: 3060-0819.

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 worksheet 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 worksheets 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.

If you do not provide the information we request on the form, the FCC may delay processing of your worksheet or may return your worksheet without action.

The foregoing Notice is required by the Privacy Act of 1974, Pub. L. No. 93-579, December 31, 1974, 5 U.S.C. Section 552, and the Paperwork Reduction Act of 1995, Pub. L. No. 104-13, 44 U.S.C. Section 3501, et seq.

Pursuant to section 54.405, all eligible telecommunications carriers (ETCs) not availing themselves to forbearance are required to provide Lifeline service. In turn, these ETCs are permitted under section 54.407 to receive support for offering Lifeline service to qualifying low-income customers. Pursuant to section 54.413 (Link Up), ETCs that also receive High Cost support may be reimbursed for providing reduced-service connection charges to eligible residents of federally recognized Tribal lands. Lifeline service providers must use FCC Form 497 to request reimbursement for participating in the Low-Income Program.

Line 1 USAC Service Provider Identification Number (SPIN) - Please enter your 9-digit USAC Service Provider Identification Number.

Line 2 Study Area Code (SAC) - Indicate the 6-digit study area code for which you are claiming reimbursement.

Box 3 Organization Information - Indicate your company's legal name and mailing address.

Contact Name, Telephone Number and Fax Number - Provide information for the individual who should be contacted with questions about this form.

E-mail Address - Indicate e-mail address of contact person listed above.

Box 4 Filing Information

a) Submission Date - The date that you are filling out this form.

b) Data Month - The month for which you are reporting data. Please submit one worksheet per month.

c) Type of filing - Check "original" box if your company is reporting this data for the first time. If this is a revision to data originally submitted, check the "revision" box. Revisions will not be accepted later than 12 months after the data month for which the revision applies. Report originals and revisions on separate forms. For revisions, all amounts should be reported as positive numbers reflecting the actual amounts that should have been claimed for the month.

d) State Reporting - Indicate in which state the ETC is claiming support.

Lifeline:

Description: The federal Lifeline Program benefits eligible low-income subscribers by reducing their voice telephony and/or broadband internet service by $9.25 per month. Tribal customers may receive a reduction of up to $34.25 off their monthly supported service charge.

Non-Tribal Lifeline: All eligible, Non-Tribal subscribers will receive $9.25 in federal support.

Tribal Lifeline: Additional federal Lifeline support of up to $25 per month is available to eligible residents of Tribal lands, as defined in 47 C.F.R. section 54.400(e).

Line 5(a) Enter the number of low-income subscribers for whom Non-Tribal Lifeline federal voice support is claimed. To claim support for a voice offering, the service offering needs to meet the applicable minimum service standard as outlined in 47 CFR §54.408.

Line 5(b) The maximum rate per subscriber is $9.25 for Non-Tribal Lifeline federal voice support.

Line 5(c) Enter the total dollar amount of Non-Tribal Lifeline federal voice support claimed (multiply Line 5(a) and Line 5(b)). Report this amount in whole dollars.

Line 6(a) Enter the number of low-income subscribers for whom Non-Tribal Lifeline federal broadband support is claimed. To claim support for a broadband offering, the service offering needs to meet the applicable minimum service standard as outlined in 47 CFR §54.408.

Line 6(b) The maximum rate per subscriber is $9.25 for Non-Tribal Lifeline federal broadband support.

Line 6(c) Enter the total dollar amount of Non-Tribal Lifeline federal broadband support claimed (multiply Line 6(a) and Line 6(b)). Report this amount in whole dollars.

Line 7(a) Enter the number of low-income subscribers for whom Non-Tribal Lifeline federal bundled support is claimed. To claim support for a bundled offering, the service offerings for both voice and broadband need to meet the applicable minimum service standards as outlined in 47 CFR §54.408. If only one of the service offerings meets the appropriate minimum service standard, then the subscriber should be included in either 5(a) or 6(a) based on the qualifying service offering.

Line 7(b) The maximum rate per subscriber is $9.25 for Non-Tribal Lifeline federal bundled support.

Line 7(c) Enter the total dollar amount of Non-Tribal Lifeline federal bundled support claimed (multiply Line 7(a) and Line 7(b)). Report this amount in whole dollars.

Line 8 Enter the total Non-Tribal Lifeline dollars claimed for the reported month. (Add Lines 5(c), 6(c), and 7(c)). Report this amount in whole dollars

Line 9(a) Enter the number of low-income subscribers for whom Tribal Lifeline federal Lifeline voice support is claimed. To claim support for a voice offering, the service offering needs to meet the applicable minimum service standard as outlined in 47 CFR §54.408.

Line 9(b) Enter the rate per subscriber for Tribal Lifeline federal voice support claimed, up to a maximum of $34.25.

Line 9(c) Enter the total dollar amount of Tribal Lifeline federal voice support claimed (multiply Line 9(a) and Line 9(b)). Report this amount in whole dollars.

Line 10(a) Enter the number of low-income subscribers for whom Tribal Lifeline federal broadband support is claimed. To claim support for a broadband offering, the service offering needs to meet the applicable minimum service standard as outlined in 47 CFR §54.408.

Line 10(b) Enter the rate per subscriber for Tribal Lifeline federal broadband support claimed, up to a maximum of $34.25.

Line 10(c) Enter total dollar amount of Tribal Lifeline federal broadband support claimed (multiply Line 1(a) and Line 10(b)). Report this amount in whole dollars.

Line 11(a) Enter the number of low-income subscribers for whom Tribal Lifeline federal bundled support is claimed. To claim support for a bundled offering, the service offerings for both voice and broadband need to meet the applicable minimum service standards as outlined in 47 CFR 54.408. If only one of the service offerings meets the appropriate minimum service standard, then the subscriber should be included in either 5(a) or 6(a) based on the qualifying service offering.

Line 11(b) Enter the rate per subscriber for Tribal Lifeline federal bundled support claimed, up to a maximum of $34.25.

Line 11(c) Enter the total dollar amount of Tribal Lifeline federal bundled support claimed (multiply Line 11(a) and Line 11(b)). Report this amount in whole dollars.

Line 12 Enter the total Tribal Lifeline federal dollars claimed for the reported month. (Add Lines 9(c), 10(c), and 11(c)). Report this amount in whole dollars

Line 13 Enter the Total Lifeline Support amount to be paid for the reported month.

Tribal Link Up:

Description: For an eligible resident of Tribal lands (as defined in 47 C.F.R. section 54.400(e)), a reduction of up to $100 is available to cover the charges assessed for commencing telecommunications service by ETC that is also receiving High Cost support.

Tribal Land Low-Income Subscribers Only (available only to ETCs receiving High Cost support)

Line 14 Enter number of Link Up subscribers residing on Tribal lands (including any federally recognized Indian tribe’s reservation, pueblo, or colony including former reservations in Oklahoma; Alaska Native Regions; Indian Allotments; or Hawaiian Home Lands) for whom connection charges were waived.

Line 15 Enter the dollar amount of Tribal Link Up claimed per subscriber. The reduction in charges should not exceed $100 in total to cover 100% of the charges up to $100 for commencing service at the principle place of residence of an eligible resident of Tribal lands.

Line 16 Enter the dollar amount of Tribal Link Up claimed (multiply Lines 14 and 15).

Line 17 Enter the dollar amount of total Link Up support. Report this amount in whole dollars.

Line 18 – Lifeline Provider Payment

This is the Total Low-Income Support amount to be paid to Lifeline Providers for the reported month. Enter the dollar amounts from Line 13 (total Lifeline support claimed) and Line 17 (total Tribal Link Up claimed). Enter the sum of these amounts on Line 19. Report this amount in whole dollars.

Line 19 - Certifications and Signatures

Page 2 of FCC Form 497 requires the signature of an officer of the company certifying under penalty of perjury that the following statements are correct (as applicable):

Certify that your company will pass through the full amount of all Non-Tribal and Tribal federal Lifeline support for which they seek reimbursement, as well as all applicable intrastate Lifeline support, to all qualifying low-income subscribers by an equivalent reduction in the subscriber's monthly bill for supported service or by offering a pre-paid wireless plan that complies with the appropriate minimum service standards. See C.F.R. 47 sections 54.403(a)-(b); 54.408.

Certify that your company is in compliance with all of the Lifeline program rules, and to the extent required, has obtained valid certifications for each subscriber for whom your company seeks reimbursement. See 47 C.F.R. § 54.407(d).

Certify that the data contained in this form has been examined and reviewed and is true, accurate, and complete.

FCC Form 497 support claims are due to USAC by the 8th of each month, or the next business day if the 8th falls on a Saturday, Sunday or federal holiday.

ETCs that file their support claim electronically on FCC Form 497 for the previous month by the 8th of the current month will be paid for the previous month's claim by the end of the current month. ETCs that do not take advantage of electronic filing (i.e., those who file via fax, e-mail or U.S. mail) will receive payment for the previous month's support claim at the end of the following month.

Forms can be submitted electronically by visiting USAC’s website, www.usac.org, and selecting “USAC Forms.”

Forms may also be emailed to [email protected], faxed to USAC at (866) 873-4665 Toll Free

(Attention: Customer Operations) or mailed to:

Universal Service Administrative Co.

Customer Operations

700 12th Street NW, Suite 900

Washington, DC 20005

NOTICE: To implement section 254 of the Communications Act of 1934, as amended, the Federal Communications Commission has adopted changes to the federal low-income programs. The Commission has expanded the availability of these programs and the level of funding for discounts to low-income customers.

The following worksheet provides the means by which eligible telecommunications carriers will be reimbursed by the Universal Service Administrative Company (USAC) for their participation in these programs. Failing to collect the information, or collecting it less frequently, would prevent the Commission from implementing sections 214 and 254 of the Act, would thwart Congress' goals of providing affordable service and access to advanced services throughout the nation, and would result in eligible telecommunications carriers not receiving universal service support reimbursements in a timely fashion.

We have estimated that each response to this collection of information will take, on average, two and one half hours for each respondent. Our estimate includes the time to read this data request, review existing records, gather and maintain required data, and complete and review the 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, AMD-PERM, Washington, D.C. 20554, Paperwork Reduction Project (3060-0819). We will also accept your comments on the burden estimate via the Internet if you send them to [email protected]. Please DO NOT SEND the data requested to this e-mail address.

Remember -- An agency may not conduct or sponsor, and a person is not required to respond to a collection of information sponsored by the Federal government unless it displays a currently valid OMB control number. This information collection has been assigned OMB Control Number: 3060-0819.

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 worksheet 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 worksheets 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.

If you do not provide the information we request on the form, the FCC may delay processing of your worksheet or may return your worksheet without action.

The foregoing Notice is required by the Privacy Act of 1974, Pub. L. No. 93-579, December 31, 1974, 5 U.S.C. Section 552, and the Paperwork Reduction Act of 1995, Pub. L. No. 104-13, 44 U.S.C. Section 3501, et seq.

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