FCC Forms 555 and 481

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Overview

Carrier Contact Information
(100)_Service Quality
(200) Voice Outages
300 Screen
400 Screen
500 Screen
600 Screen
(0700) VoicePricing
(0710) BB Pricing
(0800)_Operating Co
(0900)_Tribal Lands
(1000)_Screen
(1100) Terres Backhaul
(1200) Lifeline Term and Cond.
(2005) Price Cap Data
(3005) ROR Data
(3005) ROR Data (Cont))
(4005) RBE Data
CERTIFICATION-REPORTING CARRIER
CERTIFICATION-AGENT

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Sheet 1: Carrier Contact Information

FCC Form 481 - Carrier Annual Reporting											FCC Form 481
Data Collection Form											OMB Control No. 3060-0986/OMB Control No. 3060-0819
											July 2016
<010>	Study Area Code
<015>	Study Area Name
<020>	Program Year
<030>	Contact Name: Person USAC should contact
	with questions about this data
<035>	Contact Telephone Number:
	Number of the person identified in data line <030>
<039>	Contact Email:
	Email of the person identified in data line <030>
	Filing Type

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Sheet 2: (100)_Service Quality

(100) Service Quality Improvement Reporting									FCC Form 481
Data Collection Form									OMB Control No. 3060-0986/OMB Control No. 3060-0819
									July 2016
<010>	Study Area Code
<015>	Study Area Name
<020>	Program Year
<030>	Contact Name - Person USAC should contact regarding this data
<035>	Contact Telephone Number - Number of person identified in data line <030>
<039>	Contact Email Address - Email Address of person identified in data line <030>
<110>	Has your company received its ETC certification from the FCC?		(yes / no )
<111>	If your answer to Line <110> is yes, do you have an existing §54.202(a) "5 year plan" filed with the FCC?		(yes / no )
	If your answer to Line <111> is yes, then you are required to file a progress report, on line <112> delineating the status of your company's existing § 54.202(a) "5 year plan" on file with the FCC, as it relates to your provision of voice telephony service.
<112>	Attach Five-Year Service Quality Improvement Plan or, in subsequent years, your annual progress report filed pursuant to 47 C.F.R. § 54.313(a)(1). If your company is a CETC which only receives frozen support, your progress report is only required to address voice telephony service.
				Name of Attached Document
	Please check these boxes below to confirm that the attached PDF, on line 112, contains a progress report on its five-year service quality improvement plan pursuant to § 54.202(a). The information shall be submitted at the wire center level or census block as appropriate.
<113>	Maps detailing progress towards meeting plan targets
<114>	Report how much universal service (USF) support was received
<115>	How much (USF) was used to improve service quality and how support was used to improve service quality
<116>	How much (USF) was used to improve service coverage and how support was used to improve service coverage
<117>	How much (USF) was used to improve service capacity and how support was used to improve service capacity
<118>	Provide an explanation of network improvement targets not met in the prior calendar year.

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Sheet 3: (200) Voice Outages

(200) Service Outage Reporting (Voice)

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

<220>

For the prior calendar year, were there any reportable voice service outages?

(yes / no )

<220>

<a>

<b1>

<b2>

<b3>

<b4>

<c1>

<c2>

<d>

<e>

<f>

<g>

<h>

NORS Reference Number (if applicable)

Outage Start Date

Outage Start Time

Outage End Date

Outage End Time

Number of Customers Affected

Total Number of Customers

911 Facilities Affected (Yes / No)

Service Outage Description (Check all that apply)

Did This Outage Affect Multiple Study Areas (Yes / No)

Service Outage Resolution

Preventative Procedures

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Sheet 4: 300 Screen

(300) Unfulfilled Service Requests

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

<300>

Unfulfilled Service Requests (voice)

<310>

Detail on Attempts (voice)

Name of Attached Document

<320>

Unfulfilled Service Requests (broadband)

<330>

Detail on Attempts (broadband)

Name of Attached Document

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Sheet 5: 400 Screen

(400) Number of Complaints per 1,000 Customers

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

<400>

Select from the drop-down list to indicate how you would like to report voice complaints (zero or greater) for voice telephony service in the prior calendar year for each service area in which you are designated an ETC for any facilities you own, operate, lease, or otherwise utilize.

<410>

Complaints per 1000 customers for fixed voice

<420>

Complaints per 1000 customers for Mobil voice

<430>

Select from the drop-down list to indicate how you would like to report end-user customer complaints for broadband service in the prior calendar year for each service area in which you are designated an ETC for any facilities you own, operate, lease, or otherwise utilize.

<440>

Complaints per 1000 customers for fixed broadband

<450>

Complaints per 1000 customers for Mobil broadband

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Sheet 6: 500 Screen

(500) Compliance With Service Quality Standards and Consumer Protection Rules

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

<500>

Certify compliance with applicable minimum service standards

<510>

Certify compliance with service quality standards, and consumer protection rules

<520>

Descriptive document for Service Quality Standards & Consumer Protection Rules Compliance

Name of Attached Document

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Sheet 7: 600 Screen

(600) Functionality in Emergency Situations

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

<600>

Certify compliance regarding ability to function in emergency situations

<610>

Descriptive document for Functionality in Emergency Situations

Name of Attached Document

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Sheet 8: (0700) VoicePricing

(700) Price Offerings including Voice Rate Data							FCC Form 481
Data Collection Form							OMB Control No. 3060-0986/OMB Control No. 3060-0819
							July 2016
<010>	Study Area Code
<015>	Study Area Name
<020>	Program Year
<030>	Contact Name - Person USAC should contact regarding this data
<035>	Contact Telephone Number - Number of person identified in data line <030>
<039>	Contact Email Address - Email Address of person identified in data line <030>
<701>	FCC Local Urban Rate Floor			$$.$$
<702>	Residential Local Service Charge Effective Date			mm/dd/yyyy
<703>	<a1>	<a2>	<a3>	<b1>	<b2>	<b3>	<b4>	<b5>	<c>
	State	Exchange (ILEC)	SAC (CETC)	Rate Type	Residential Local Service Rate	State Subscriber Line Charge	State Universal Service Fee	Mandatory Extended Area Service Charge	Total per line Rates and Fees

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Sheet 9: (0710) BB Pricing

(710) Broadband Price Offerings								FCC Form 481
Data Collection Form								OMB Control No. 3060-0986/OMB Control No. 3060-0819
								July 2016
<010>	Study Area Code
<015>	Study Area Name
<020>	Program Year
<030>	Contact Name - Person USAC should contact regarding this data
<035>	Contact Telephone Number - Number of person identified in data line <030>
<039>	Contact Email Address - Email Address of person identified in data line <030>
<711>	<a1>	<a3>	<b1>	<b2>	<c>	<d1>	<d2>	<d3>	<d4>
	State	Exchange (ILEC)	Residential Rate	State Regulated Fees	Total Rate and Fees	Broadband Service - Download Speed (Mbps)	Broadband Service - Upload Speed (Mbps)	Usage Allowance (GB)	Usage Allowance Action Taken When Limit Reached {select }

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Sheet 10: (0800)_Operating Co

(800) Operating Companies

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

<810>

Reporting Carrier

<811>

Holding Company

<812>

Operating Company

<813>

<a1>

<a2>

<a3>

Affiliates

SAC

Doing Business As Company or Brand Designation

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Sheet 11: (0900)_Tribal Lands

(900) Tribal Lands Reporting						FCC Form 481
Data Collection Form						OMB Control No. 3060-0986/OMB Control No. 3060-0819
						July 2016
<010>	Study Area Code
<015>	Study Area Name
<020>	Program Year
<030>	Contact Name - Person USAC should contact regarding this data
<035>	Contact Telephone Number - Number of person identified in data line <030>
<039>	Contact Email Address - Email Address of person identified in data line <030>
<900>	Does the filing entity offer tribal land services? (Y/N)
<910>	Tribal Land(s) on which ETC Serves
<920>	Tribal Government Engagement Obligation
				Name of Attached Document (.pdf)
	If your company serves Tribal lands, please select (Yes,No, NA) for each these boxes to confirm the status described on the attached PDF, on line 920, demonstrates coordination with the Tribal government pursuant to § 54.313(a)(9) includes:
			Select (Yes,No, NA)
<921>	Needs assessment and deployment planning with a focus on Tribal community anchor institutions;
<922>	Feasibility and sustainability planning;
<923>	Marketing services in a culturally sensitive manner;
<924>	Compliance with Rights of way processes
<925>	Compliance with Land Use permitting requirements
<926>	Compliance with Facilities Siting rules
<927>	Compliance with Environmental Review processes
<928>	Compliance with Cultural Preservation review processes
<929>	Compliance with Tribal Business and Licensing requirements.

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Sheet 12: (1000)_Screen

(1000) Voice and Broadband Service Rate Comparability

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

<1000>

Voice Services Rate Comparability Certification

<1010>

Attach Detailed Description for Voice Services Rate Comparability Compliance

Name of Attached Document

<1020>

Broadband comparability certification

<1030>

Attach Detailed Description for Broadband Comparability Compliance

Name of Attached Document

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Sheet 13: (1100) Terres Backhaul

(1100) Terrestrial Backhaul Reporting						FCC Form 481
Data Collection Form						OMB Control No. 3060-0986/OMB Control No. 3060-0819
						July 2016
<010>	Study Area Code
<015>	Study Area Name
<020>	Program Year
<030>	Contact Name - Person USAC should contact regarding this data
<035>	Contact Telephone Number - Number of person identified in data line <030>
<039>	Contact Email Address - Email Address of person identified in data line <030>
<1100>	Terrestrial Backhaul (Y/N)
<1130>	Please select the appropriate response (Yes, No, Not Applicable) to confirm the reporting carrier offers broadband service of at least 1 Mbps downstream and 256 kbps upstream within the supported area pursuant to § 54.313(G)

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Sheet 14: (1200) Lifeline Term and Cond.

(1200) Terms and Condition for Lifeline Customers						FCC Form 481
Lifeline						OMB Control No. 3060-0986/OMB Control No. 3060-0819
Data Collection Form						July 2016
<010>	Study Area Code
<015>	Study Area Name
<020>	Program Year
<030>	Contact Name - Person USAC should contact regarding this data
<035>	Contact Telephone Number - Number of person identified in data line <030>
<039>	Contact Email Address - Email Address of person identified in data line <030>
<1210>	Terms & Conditions of Voice Telephony Lifeline Plans
			Name of attached document (.pdf)
<1220>	Link to Public Website	HTTP
	Please check these boxes below to confirm that the attached document(s), on line 1210, or the website listed, on line 1220, contains the required information pursuant to § 54.422(a)(2) annual reporting for ETCs receiving low-income support, carriers must annually report:
<1221>	Information describing the terms and conditions of any voice telephony service plans offered to Lifeline subscribers,
<1222>	Details on the number of minutes provided as part of the plan,
<1223>	Additional charges for toll calls, and rates for each such plan.

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Sheet 15: (2005) Price Cap Data

(2005) Price Cap Carrier Additional Documentation

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

Including Rate-of-Return Carriers affiliated with Price Cap Local Exchange Carriers

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

Select the appropriate responses below (Yes, No, Not Applicable) to note compliance as a recipient of Incremental Connect America Phase I support, frozen High Cost support, High Cost support to offset access charge reductions, and Connect America Phase II support as set forth in 47 CFR § 54.313(b),(c),(d),(e). The information reported on this form and in the documents attached below is accurate.

Incremental Connect America Phase I reporting

<2010>

2nd Year Certification {47 CFR § 54.313(b)(1)i} - Note that for the July 1, 2016 certification, this applies to Round 2 recipients of Incremental Support

<2011>

3rd Year Certification {47 CFR § 54.313(b)(1)ii} - Note that for the July 1, 2016 certification, this applies to Round 1 recipients of Incremental Support

Name of Attached Document Listing Required Information

<2022>

Recipient certifies, representing year two after filing a notice of acceptance of funding pursuant to 54.312(c), that the locations in question are not receiving support under the Broadband Initiatives Program or the Broadband Technology Opportunities Program for projects that will provide broadband with speeds of at least 4 Mbps/1Mbps - 54.313(b)(2)(i). Round 2 recipients only.

<2023>

The attachment on Line 2024 includes a statement of the total amount of capital funding expended in the previous year in meeting Connect America Phase I deployment obligations, accompanied by a list of census blocks indicating where funding was spent. This covers year two - 54.313(b)(2)(ii). Round 2 recipients only.

<2024A>

Round 2 Recipient of Incremental Support?

<2024B>

Attach list of census blocks indicating where funding was spent in year two - 54.313(b)(2)(ii). Round 2 recipients only.

Name of Attached Document Listing Required Information

<2025A>

Round 1 or Round 2 Recipient of Incremental Support?

<2025B>

Attach Geocoded Information for Phase I milestone reports (Round 1 for year three and Round 2 for year two) - Connect American Fund , WC Docket 10-90, Report and Order, FCC 13-73, paragraph 35 (May 22, 2013).

Name of Attached Document Listing Required Information

Price Cap Carrier Receiving Frozen Support Certification {47 CFR § 54.312(a)}

<2015>

2016 and future Frozen Support Certification {47 CFR § 54.313(c)(4)}

Price Cap Carrier Connect America ICC Support {47 CFR § 54.313(d)}

<2016>

Certification Support Used to Build Broadband

Connect America Phase II Reporting {47 CFR § 54.313(e)}

<2017A>

Connect America Fund Phase II recipient?

<2017B>

Attach Information for Phase II - 54.313(e)(1) - list of geocoded locations already meeting the 54.309 public interest obligations at the end of calendar year 2015 and total amoount of Phase II support, if any, the price cap carrier used for capital expenditures in 2015.

Name of Attached Document Listing Required Information

<2018>

Attach the number, names, and addresses of community anchor institutions to which the carrier newly began providing access to broadband service in the preceding calendar year - 54.313(e)(2)(ii)

Name of Attached Document Listing Required Information

<2019>

Recipient certifies that it bid on category one telecommunications and Internet access services in response to all FCC Form 470 postings seeking broadband service that meets the connectivity targets for the schools and libraries universal service support program for eligible schools and libraries located within any area in a census block wehre the carrier is receiving Phase II model-based support, and that such bids were at rates reasonably comparable to rates charged to eligible schools and libraries in urban areas for comparable offerings - 54.313(e)(2)(v)

<2020>

Recipient certifies that it offered broadband meeting the requisite public interest obligations specified in §54.309 to 40% of its supported locations in the state on December 31, 2017 - 54.313(e)(3)

<2021>

Recipient certifies that it offered broadband meeting the requisite public interest obligations specified in §54.309 to 60% of its supported locations in the state on December 31, 2018 - 54.313(e)(4)

<2026>

Recipient certifies that it offered broadband meeting the requisite public interest obligations specified in §54.309 to 80% of its supported locations in the state on December 31, 2019 - 54.313(e)(5)

<2027>

Recipient certifies that it offered broadband meeting the requisite public interest obligations specified in §54.309 to 100% of its supported locations in the state on December 31, 2020 - 54.313(e)(6)

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Sheet 16: (3005) ROR Data

(3005) Rate Of Return Carrier Additional Documentation

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

CHECK the boxes below to note compliance on its five year service quality plan (pursuant to 47 CFR § 54.202(a)) and, for privately held carriers, ensuring compliance with the financial reporting requirements set forth in 47 CFR § 54.313(f)(2). I further certify that the information reported on this form and in the documents attached below is accurate.

Progress Report on 5 Year Plan

(3009)

Carrier certifies to 54.313(f)(1)(iii) regarding FCC Form 470

(3010A)

Milestone Certification {47 CFR § 54.313(f)(1)(i)}

(3010B)

Please Provide Attachment

Name of Attached Document Listing Required Information

(3012A)

Community Anchor Institutions {47 CFR § 54.313(f)(1)(ii)}

(3012B)

Please Provide Attachment

Name of Attached Document Listing Required Information

(3013)

Is your company a Privately Held ROR Carrier {47 CFR § 54.313(f)(2)}

(Yes/No)

(3014)

If yes, does your company file the RUS annual report

(Yes/No)

Please check these boxes to confirm that the attached PDF, on line 3017, contains the required information pursuant to § 54.313(f)(2) compliance requires:

(3015)

Electronic copy of their annual RUS reports (Operating Report for Telecommunications Borrowers)

(3016)

PDF of Balance Sheet, Income Statement and Statement of Cash Flows

(3017)

If the response is yes on line 3014, attach your company's RUS annual report and all required documentation

Name of Attached Document Listing Required Information

(3018)

If the response is no on line 3014, Is your company audited?

(Yes/No)

If the response is yes on line 3018, please check the boxes below to

confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains :

(3019)

Either a copy of their audited financial statement; or (2) a financial report in a format comparable to RUS Operating Report for Telecommunications Borrowers

(3020)

PDF of Balance Sheet, Income Statement and Statement of Cash Flows

(3021)

Management letter issued by the independent certified public accountant that performed the company’s financial audit.

If the response is no on line 3018, please check the boxes below to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains:

(3022)

Copy of their financial statement which has been subject to review by an independent certified public accountant; or 2) a financial report in a format comparable to RUS Operating Report for Telecommunications Borrowers,

(3023)

Underlying information subjected to a review by an independent certified public accountant

(3024)

Underlying information subjected to an officer certification.

(3025)

PDF of Balance Sheet, Income Statement and Statement of Cash Flows

(3026)

Attach the worksheet listing required information

Name of Attached Document Listing Required Information

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Sheet 17: (3005) ROR Data (Cont))

(3005) Rate Of Return Carrier Additional Documentation (Continued)

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

Financial Data Summary

(3027)

Revenue

(3028)

Operating Expenses

(3029}

Net Income

(3030)

Telephone Plant In Service (TPIS)

(3031)

Total Assets

(3032)

Total Debt

(3033)

Total Equity

(3034)

Dividents

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Sheet 18: (4005) RBE Data

(4005) Rural Broadband Experiment Additional Documentation

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

4005 Rural Broadband Experiment

Authorized Rural Broadband Experiment (RBE) recipients must address the certification for public interest obligations, provide a list of newly served community anchor institutions, and provide a list of locations where broadband has been deployed.

Public Interest Obligations – FCC 14-98 (paragraphs 26-29, 78)

Please address Line 4001 regarding compliance with the Commission’s public interest obligations. All RBE participants must provide a response to Line 4001.

4001. Recipient certifies that it is offering broadband to the identified locations meeting the requisite public interest obligations consistent with the category for which they were selected, including broadband speed, latency, usage capacity, and rates that are reasonably comparable to rates for comparable offerings in urban areas?

Community Anchor Institutions – FCC 14-98 (paragraph 79)

4003a. RBE participants must provide the number, names, and addresses of community anchor institutions to which they newly deployed broadband service in the preceding calendar year. On this line, please respond (yes – attach new community anchors, no – no new anchors) to indicate whether this list will be provided.

If yes to 4003A, please provide a response for 4003B.

4003b. Provide the number, names and addresses of community anchor institutions to which the recipient newly began providing access to broadband service in the preceding calendar year.

Name of Attached Document Listing Required Information

Broadband Deployment Locations – FCC 14-98 (paragraph 80)

4004a. Attach a list of geocoded locations to which broadband has been deployed as of the June 1st immediately preceding the July 1st filing deadline for the FCC Form 481.

Name of Attached Document Listing Required Information

4004b. Attach evidence demonstrating that the recipient is meeting the relevant public service obligations for the identified locations. Materials must at least detail the pricing, offered broadband speed and data usage allowances available in the relevant geographic area.

Name of Attached Document Listing Required Information

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Sheet 19: CERTIFICATION-REPORTING CARRIER

Certification - Reporting Carrier

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

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

Certification of Officer as to the Accuracy of the Data Reported for the Annual Reporting for CAF or LI Recipients

I certify that I am an officer of the reporting carrier; my responsibilities include ensuring the accuracy of the annual reporting requirements for universal service support recipients; and, to the best of my knowledge, the information reported on this form and in any attachments is accurate.

Name of Reporting Carrier:

Signature of Authorized Officer:

Date

Printed name of Authorized Officer:

Title or position of Authorized Officer:

Telephone number of Authorized Officer:

Study Area Code of Reporting Carrier:

Filing Due Date for this form:

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Sheet 20: CERTIFICATION-AGENT

Certification - Agent / Carrier

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2016

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

Contact Telephone Number - Number of person identified in data line <030>

<039>

Contact Email Address - Email Address of person identified in data line <030>

TO BE COMPLETED BY THE REPORTING CARRIER, IF AN AGENT IS FILING ANNUAL REPORTS ON THE CARRIER'S BEHALF:

Certification of Officer to Authorize an Agent to File Annual Reports for CAF or LI Recipients on Behalf of Reporting Carrier

I certify that (Name of Agent)_______________________________________________________ is authorized to submit the information reported on behalf of the reporting carrier. I also certify that I am an officer of the reporting carrier; my responsibilities include ensuring the accuracy of the annual data reporting requirements provided to the authorized agent; and, to the best of my knowledge, the reports and data provided to the authorized agent is accurate.

Name of Authorized Agent:

Name of Reporting Carrier:

Signature of Authorized Officer:

Date:

Printed name of Authorized Officer:

Title or position of Authorized Officer:

Telephone number of Authorized Officer:

Study Area Code of Reporting Carrier:

Filing Due Date for this form:

TO BE COMPLETED BY THE AUTHORIZED AGENT:

Certification of Agent Authorized to File Annual Reports for CAF or LI Recipients on Behalf of Reporting Carrier

I, as agent for the reporting carrier, certify that I am authorized to submit the annual reports for universal service support recipients on behalf of the reporting carrier; I have provided the data reported herein based on data provided by the reporting carrier; and, to the best of my knowledge, the information reported herein is accurate.

Name of Reporting Carrier:

Name of Authorized Agent Firm:

Signature of Authorized Agent or Employee of Agent:

Date:

Name of Authorized Agent Employee:

Title or position of Authorized Agent or Employee of Agent

Telephone number of Authorized Agent or Employee of Agent:

Study Area Code of Reporting Carrier:

Filing Due Date for this form: