Form FCC 5625 FCC 5625 Connect America Phase II New York Long Form Application

FCC Form 5625 Main Form

Connect America Phase II New York

Long-Form Application—Main Form

OMB Approved 3060-XXXX Estimated Time Per Response: 4 hours

_________ 2017

Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.

1 Date Submitted:

Applicant Information

[[]]

2 Applicant Legal Classification

Consortium Corporation General Partnership Government Entity Individual Limited Liability Company

Limited Liability Partnership Limited Partnership Trust Unincorporated Association Other: _______________________________

3 Entity Name

4 FCC Registration Number (FRN)

5 Jurisdiction of Formation

6 Address Line 1

7 Address Line 2

8 City

9 State

10 Zip Code

11 Phone

Ext.

12 Email

Contact Information

13 Name

14 Organization

15 Address Line 1

16 Address Line 2

17 City

18 State

19 Zip Code

20 Phone

Ext.

21 Email

Ownership Information

For each Disclosable Interest Holder, complete and attach a Schedule A. If there are any Disclosable Interest Holders with indirect ownership of the applicant, attach a separate exhibit showing the relationship between those Disclosable Interest Holders and the applicant. If there is insufficient space to provide complete lists of Disclosable Interest Holders and FCC-Regulated Businesses below, provide those lists in attachments to this form. See 47 C.F.R. § 1.2112(a).

22 Disclosable Interest Holders

Name

Type of Entity

FRN

Percent Interest Held

23 FCC-Regulated Businesses (Held by Applicant)

Name

Principal Business

FRN

Percent Interest Held

Required Attachments

24 ETC Designation

Is the applicant designated as an eligible telecommunications carrier (ETC)?

• Yes, the applicant has already been designated as an ETC in the areas where it is seeking Connect America Phase II support. The relevant designation order is attached to this application.

• No, the applicant has not been designated as an ETC in the areas where it is seeking Connect America support. The applicant is in the process of applying for ETC designation in the relevant areas and will submit the designation order and accompanying certification to the Commission upon being designated as an ETC.

24 Construction Funding Documentation

In an exhibit attached to this form, describe how the required construction will be funded, including financial projections that demonstrate the applicant’s ability to cover the necessary debt service payments over the life of the loan, if any.

25 Network Design Documentation

In an exhibit attached to this form, describe how the technology and system design the applicant intends to use will deliver voice and broadband service, including a network diagram which must be certified by a professional engineer. The professional engineer must certify that the network is capable of delivering, to at least 95 percent of the required number of locations in each relevant state, voice and broadband service that meets the requisite performance requirements. See 47 C.F.R. § 54.309. There must be sufficient capacity to meet customer demand at or above the prescribed levels during peak usage periods. Entities proposing to use wireless technologies also must provide a description of their spectrum access in the areas for which they seek support and demonstrate that they have the required licenses to use that spectrum, if applicable.

Audited Financial Statements

26 Is the applicant providing three years of audited financial statements to New York for participation in the New NY Broadband program? Applicants that are not providing three years of audited financial statements to New York must, in addition to submitting other information to New York, submit financial statements from the prior fiscal year that are audited by a certified public accountant before they will be authorized to receive Connect America Phase II support no later than 180 days after the public notice identifying them as winning bidders.

• Yes

• No

Certifications

By signing below, the authorized officer certifies the following statements on behalf of the applicant.

The applicant certifies that it is financially and technically qualified to meet the public interest obligations in each area for which it seeks support.

The applicant certifies that it will meet the relevant public interest obligations, including the requirement that it will offer service at rates that are equal to or lower than the Commission’s reasonable comparability benchmarks for fixed wireline services offered in urban areas.

The applicant certifies that it will have available funds for all project costs that exceed the amount of Connect America support authorized by the Commission to be received for the first two years of its support term and that the applicant will comply with all program requirements.

The applicant certifies that it and any party to the application are not subject to a denial of federal benefits pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988.

The applicant certifies that the party submitting these certifications is authorized to do so on behalf of the applicant.

I, the individual identified as the applicant’s certifying representative below, declare under penalty of perjury that, based on all the information available to the applicant, all the information provided in or with this application, including the certification statements above, are true and correct.

27 Signature

28 Date

29 Printed Name of Authorized Officer

30 Title/Position of Authorized Officer

31 Phone Ext.

32 Email

33 Employer

Persons willfully making false statements on this form can be punished by fine or forfeiture under the Communications Act, 47

U.S.C. Secs. 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT

Part 3 of the Commission’s Rules authorize the FCC to request the information on this form. The purpose of the information is to determine whether applicants can meet the terms and conditions of Connect America Phase II support. The information will be used by the Universal Service Administrative Company and/or the staff of the Federal Communications Commission, to evaluate this form, to provide information for enforcement and rulemaking proceedings and to maintain a current inventory of applicants. No authorization can be granted unless all information requested is provided. Failure to provide all requested information will delay the processing of the application or result in the application being returned without action. Information requested by this form will be available for public inspection. Your response is required to obtain the requested authorization.

The public reporting for this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the required data, and completing and reviewing the collection of information. If you have any comments on this burden estimate, or how we can improve the collection and reduce the burden it causes you, please write to the Federal Communications Commission, AMD-PERM, Paperwork Reduction Act Project (3060-[[xxxx]]), Washington, DC 20554. We will also accept your comments regarding the Paperwork Reduction Act aspects of this collection via the Internet if you send them to [email protected]. PLEASE DO NOT

SEND YOUR RESPONSE TO THIS ADDRESS.

Remember - You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-[[xxxx]].

THE FOREGOING NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5

U.S.C. 552a(e)(3) AND THE PAPEWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

FCC Form 5625 Schedule A

Connect America Phase II New York

Basic Information

Provide the information on this Schedule A for one Disclosable Interest Holder of the applicant. Separate Disclosable Interest Holders require separate copies of Schedule A. Disclosable Interest Holders that do not have an FCC Registration Number (FRN) are not required to provide an FRN below.

1 Entity or Individual Name

2 Disclosable Interest Holder Legal Classification

Consortium Corporation General Partnership Government Entity Individual Limited Liability Company

Limited Liability Partnership Limited Partnership Trust Unincorporated Association Other: _______________________________

3 FCC Registration Number (FRN)

4 Jurisdiction of Formation/Country of Citizenship

5 Address Line 1

6 Address Line 2

7 City

8 State

9 Zip Code

Type of Interest in Applicant

10 Check all that apply.

Direct Ownership Interest in Applicant Indirect Ownership Interest in Applicant Officer Director

Key Management Personnel Management Contract Other: _______________________________

Type of Ownership Interest in Applicant

11 If the disclosable interest holder has an ownership interest in the applicant, check all that apply below.

Common Stock (specify) Voting Non-Voting General Partnership Shares (specify) Managing Non-Managing Limited Partnership Shares (specify) Insulated Non-Insulated Membership Shares

Option to Acquire Equity Proprietorship Preferred Stock (specify both voting and convertible types) Voting Non-Voting Convertible Non-Convertible Warrant Other: _______________________________

FCC-Regulated Businesses

If there is insufficient space to provide a complete list of the Disclosable Interest Holder’s FCC-Regulated Businesses below, provide a complete list in an attachment.

12 FCC-Regulated Businesses (Held by Disclosable Interest Holder)

Name

Principal Business

FRN

Percent Interest Held

Long-Form Application—Disclosable Interest Holder Information