FCC 509 Actual Cost and Revenue Date

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Overview

ANN. CAF BLS COSTS
509 CERT.-REPORTING CARRIER
509 CERTIFICATION-AGENT
509 NOTICE

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Sheet 1: ANN. CAF BLS COSTS

CONNECT AMERICA FUND-BROADBAND LOOP SUPPORT ACTUAL COST AND REVENUE 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 CAF-BLS by Study Area
9	Annual Common Line Costs for the reporting period	amount in $
10	Annual Consumer Broadband-Only Loop Costs for the reporting period	amount in $
11	Annual SLC Revenues for the reporting period	amount in $
12a	Average Monthly Broadband-Only Loops	numeric digits
12b	Average Monthly Broadband-Only Loops * 12 * $42	amount in $
12c	Lesser of Annual Consumer Broadband-Only Loop Costs or Average Monthly Broadband-Only Loops * 12 * $42	amount in $
12d	Blended Average of Consumer Broadband-Only rates charged during time period pursuant to Section 69.132	amount in $
12e	Apply Row 12d * Row 12a * 12 months	amount in $
12	Annual Consumer Broadband-Only Revenues for the reporting period (Provide the greater of Row 12c or Row 12e)	amount in $
13	Annual Special Access Surcharges for the reporting period	amount in $
14	Annual Line Port Costs in Excess of Basic Analog Service for the reporting period	amount in $

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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, Connect America Fund-Broadband Loop Support Mechanism Annual CAF-BLS Actual Cost and Revenue Data Collection Form, on Behalf 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

Email address 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)

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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, Connect America Fund-Broadband Loop Support Mechanism Annual CAF-BLS Actual Cost and Revenue 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

Email address 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, Connect America Fund-Broadband Loop Support Annual CAF BLS Actual Cost and Revenue 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

Email address 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)

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Sheet 4: 509 NOTICE