FCC 508 Project Connect America Fund-Broadband Loop Support

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Overview

PROJ. CAF BLS.
508 CERT.-REPORTING CARRIER
508 CERTIFICATION-AGENT
508 NOTICE

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Sheet 1: PROJ. CAF BLS.

PROJECTED CONNECT AMERICA FUND-BROADBAND LOOP SUPPORT
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)	07/01/20yy - 06/30/20yy
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 - Projected CAF-BLS by Study Area
9	Projected Common Line Revenue Requirement (July 1-June 30)	amount in $
10	Projected Consumer Broadband-Only Revenue Requirement (July 1- June 30)	amount in $
11	Projected SLC Revenues (July 1-June 30)	amount in $
12a	Forcecasted Average Monthly Consumer Broadband-only Loops	numeric digits
12b	Imputed Consumer Broadband-only Revenues (Forecasted Average Monthly Consumer Broadband-only Loops * 12 * $42)	amount in $
12	Projected Consumer Broadband-Only Loop Revenues (July 1- June 30)	amount in $
13	Projected Special Access Surcharges (July 1-June 30)	amount in $
14	Projected Line Port Costs in Excess of Basic Analog Service (July 1-June 30)	amount in $

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Sheet 2: 508 CERT.-REPORTING CARRIER

TO BE COMPLETED BY THE REPORTING CARRIER, IF THE REPORTING CARRIER IS FILING FCC FORM 508 ON ITS OWN BEHALF:

Certification of Officer or Employee as to the Accuracy of the Data Reported in FCC Form 508, Connect America Fund-Broadband Loop Support Mechanism Projected CAF-BLS 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

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: 508 CERTIFICATION-AGENT

TO BE COMPLETED BY THE REPORTING CARRIER, IF AN AGENT IS FILING FCC FORM 508 ON THE CARRIER'S BEHALF:

Certification of Officer or Employee to Authorize an Agent to File FCC Form 508, Connect America Fund-Broadband Loop Support Mechanism Projected CAF-BLS 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 508, Connect America Fund-Broadband Loop Support Mechanism Projected CAF-BLS 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 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: 508 NOTICE