PRA Template Form 481 FY2021 12.10.2020 clean

High-Cost Universal Service Support

PRA Template Form 481 FY2021 12.10.2020 clean

OMB: 3060-0986

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OMB Control No. 3060-0986 (High-Cost)
OMB Control No. 3060-0819 (Low-Income)

[Month] 2020


Overview of FCC Form 481

Annual Reporting for High-Cost and Low-Income Universal Service Support Recipients via Online System

(Note: This is a representative description of the information to be collected via the online system for the FCC Form 481 and is not intended to be a visual representation of what filers will see.)

Line Number

Field Description

Purpose/Instructions

010

Study Area Code (SAC)

Study Area codes applicable to data filed.

015

Study Area Name

The standard name used to identify your study area. Typically the name is the same as your company name.

020

Program Year

The upcoming calendar year.

030

Contact Name

Name of the individual that prepared the data submission for your company.

035

Contact Phone Number

Telephone number of the individual that prepared the data submission for your company.

039

Contact Email Address

The email address of the individual that prepared the data submission for your company.

210

Voice Telephony Service Outage Reporting

Respond with ‘yes’ or ‘no’ if there were any reportable voice service outages in the prior calendar year.

220 (column a)

NORS Reference Number

Reference number associated with the data, for this outage incident, that was reported on the Network Outage Reporting System.

220 (column b1)

Outage Start Date

Date of the onset of the service outage. (format mm/dd/yyyy)

220 (column b2)

Outage Start Time

Time of the onset of the service outage. (format: hh/mm)

220 (column b3)

Outage End Date

Date of the end of the service outage.

220 (column b4)

Outage End Time

Time of the end of the service outage.

220 (column c1)

Number of Customers Affected

Total number of customers affected at any time during the service outage

220 (column c2)

Total Number of Customers

Amount of the study area’s total customer base.

220 (column d)

911 Facilities Affected (yes/no)

Confirm whether the outage impacted the 911 facilities’ functionality at any time during the service outage.

220 (column e)

Service Outage Description

Provide which services were affected by the service outage.

220 (column f)

Did this Service Outage Affect Multiple Study Areas

Answer yes or no if this service outage affected multiple study areas.

220 (column g)

Service Outage Resolution

Brief description of the processes used to resolve the service outage.

220 (column h)

Preventative Procedures

Brief description of the preventative procedures implemented by the carrier to avoid the occurrence of a similar service outage in the future.

400

Number of Complaints per 1,000 Customers (Voice Telephony Service)

Indicate the type(s) of voice services offered in the service area for any facilities you own, operate, lease, or otherwise utilize.

410

Complaints per 1000 customers for fixed voice

Number of Complaints per 1,000 customers for voice (fixed).

420

Complaints per 1000 customers for mobile voice

Number of Complaints per 1,000 customers for voice (mobile).

515

Certify compliance with applicable minimum service standards

Indicate yes or no to certify for compliance with applicable minimum service standards.

600

Certify compliance regarding ability to function in emergency situations

Answer yes or no to indicate that the carrier is able function in emergency situations.

610

Descriptive document for Functionality in Emergency Situations

Attach a PDF that provides details of the carrier’s preparedness to ensure continued service during an emergency situation.

810

Reporting Carrier

Name associated with the study area reported in this document

811 (a-d)

Holding Company

Name of the corporate holding company associated with the study area reported in this document.

812

Operating Company

Name of the corporate operating company designation associated with the study area reported in this document.

813 (column a1)

Affiliates

Name of any corporate affiliates associated with the study area reported In this document.

813 (column a2)

SAC

SAC associated with the affiliate ETCs.

813 (column a3)

Doing Business As Company or Brand Designation

The alternate corporate branding or legal “Doing Business As” designations associated with the study area reported in this document.

900

Does the filing entity offer tribal land services? (Y/N)

Answer Yes or No to indicate if the carrier has Tribal Land offerings.

910

Tribal Land(s) on which ETC Serves

Name of Tribal Land(s) on which the carrier provides service.

920

Tribal Government Engagement Obligation

PDF that outlines discussions the carrier has had with the Tribal governments.

921

Needs assessment and deployment planning with a focus on Tribal

Community anchor institutions.

Answer yes, no, or not applicable n/a to explain as to attached document, on line 920, contains an explanation of your company’s actions to address needs assessment and deployment planning with a focus on Tribal community anchor institutions for the Tribal land network.

922

Feasibility and sustainability planning;

Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to address feasibility and sustainability planning for the Tribal land network.

923

Marketing services in a culturally sensitive manner

Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to address the marketing of services in a culturally sensitive manner in the Tribal land.

924

Compliance with Rights of way processes

Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to comply with the right-of-way processes for the Tribal lands.

925

Compliance with Land Use permitting requirements

Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to comply with the land use permitting requirements for the Tribal lands.

926

Compliance with Facilities Siting rules

Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to comply with the facilities siting rules for the Tribal lands.

927

Compliance with Environmental Review processes

Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to comply with the environmental review processes for the Tribal lands.

928

Compliance with Cultural Preservation review processes

Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to comply with the cultural preservation review processes for the Tribal lands.

929

Compliance with Tribal Business and Licensing requirements.

Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to comply with the Tribal business and licensing requirements for the Tribal lands.

1000

Voice services rate comparability certification

Answer yes, no, or not applicable to certify that your pricing of fixed voice services is no more than two standard deviations above the applicable national average urban rate for voice service.

1010

Attach detailed description for voice services rate

comparability compliance

Provide a description of how your pricing of fixed voice services is no more than two standard deviations above the applicable national average urban rate for voice service, as published annually by the Wireline Competition Bureau.

1020

Broadband comparability certification

Answer yes, no, or not applicable to certify that the pricing of a service that meets the Commission’s broadband public interest obligations is no more than the applicable benchmark to be announced annually in a public notice issued by the Wireline Competition Bureau or is no more than the non-promotional price charged for a comparable fixed wireline service in urban areas in the states or U.S. Territories where the eligible telecommunications carrier receives support.

1030

Attach detailed description for broadband

comparability compliance

Provide a detailed description of how your pricing of broadband services satisfies broadband service rate comparability requirements.

1100

Certify whether terrestrial backhaul options exist (Y/N)

Confirm (yes / no) whether terrestrial backhaul options exist (yes) or whether you’re compelled to rely exclusively on satellite backhaul in your study area (no).

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).

Respond (either yes, no, or not applicable) to denote whether your company offers broadband service of at least 1 Mbps downstream and 256 kbps upstream within the supported area pursuant to § 54.313(g). This question is not applicable to companies receiving Alaska Plan support.

1140

Alaska Plan rate-of-return certification (yes, no, or not applicable) of

Compliance with approved performance plan.

Answer yes, no, or not applicable to denote whether in the portion(s) of your study area that relies exclusively on satellite backhaul, your company is providing service consistent with its approved performance plan.

1210

Terms & Conditions of Voice Telephony Lifeline Plans

Attach a document which details the terms and conditions of any voice telephony service plans.

1220

Link to Public Website

Provide public website that details the terms and conditions of any voice telephony service plans.

1221

Information describing the terms and conditions of any voice

telephony service plans offered to Lifeline subscribers,

Confirm that the attached document, on line 1210, or the website address, on line 1220, contains an explanation of 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,

Confirm that the attached document, on line 1210, or the website address, on line 1220, contains an explanation of the number of minutes provided as part of all plans offered in Lifeline subscribers.

1223

Additional charges for toll calls, and rates for each such plan.

Confirm that the attached document, on line 1210, or the website address, on line 1220, contains an explanation of the additional charges, if any, for toll calls, and rates as part of all plans offered to Lifeline subscribers.

2015

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

Answer yes or no as to whether you are compliant with 54.313(c) (4). If you do not receive Frozen support, select ‘Not Applicable’ from the drop-down menu.

2016

Certification support used to build broadband

Answer yes or no as to whether you are compliant with 54.313(d). If you do not receive ICC support, Select Not Applicable from the drop-down menu.

2017 (a)

Connect America Fund Phase II recipient?

Answer yes or no if you are a CAF Phase II Recipient.

2017 (c)

Total amount of Phase II support, if any, the price cap carrier used for capital expenditures in 2017.

Enter the total amount of Phase II Support, if any, the carrier used for capital expenditures.

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)(1)(ii)(A)

Upload a list containing 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.

2019

Connect America Phase II - FCC Form 470 Postings:

For the filing due July 1 following full implementation of this requirement, answer yes, no, or not applicable to this certification request.

3007

Does this filing retain a Cost Consultant and/or Cost Consultant Firm or Third Party to prepare financial and operations data disclosures submitted to the National Exchange Carrier Association (NECA), the Administrator, or the Commission?

Answer yes or no if there was a cost consultant and/or consultant firm, or other third party, involved in preparing the disclosures or any financial data in the prior year.

3007a

Name(s) of Consultant/Third Party

Enter the name(s) of any cost consultant or third party that helped in preparing the disclosures or any financial data.

3007b

Name(s) of Consultant Firm

Enter the name(s) of the cost consultant firm associated with the cost consultant named in line 3007a.

3009

Progress Report

Answer yes, no, or not applicable to this certification request. Rate-of-return carrier recipients of high-cost support must respond affirmatively that it bid on category one telecommunications and Internet access services in response to all reasonable requests in posted FCC Form 470s seeking broadband service that meets the connectivity targets for the schools and libraries universal service support program for eligible schools and libraries within its service area, and that such bids were at rates reasonably comparable to rates charged to eligible schools and libraries in urban areas for comparable offerings.

3010a

Certification of Public Interest Obligations

Answer yes - attach certification, no – attach explanation, or not applicable – no attachment required, to indicate whether this certification may be provided.

3010b

Please Provide Attachment

Attach a document either providing the certification stated (if yes) or an explanation of non-compliance (if no).

3012a

Rate-of-Return Community Anchor Institutions

Indicate if the carrier newly deployed broadband service to community anchor institution(s) in the previous calendar year.

3012b

Please Provide Attachment

Using link, download template and list the number, name and address for each community anchor institution. Attach the document which contains the community anchor institution details as required by 47 C.F.R. § 54.313(f)(1)(ii).

3013

Is your company a Privately Held ROR Carrier

Indicate whether your carrier is a privately held Rate of Return carrier as defined in 47 CFR 54.313(f)(2)

3014

If yes, does your company file the RUS annual report

Indicate whether your carrier files the RUS annual report.

3015

Electronic copy of their annual RUS reports

(Operating Report for Telecommunications

Borrowers)

Check the box to confirm that a copy of the RUS annual report is provided as part of the document uploaded to Line 3017.

3016

Document(s) with Balance Sheet, Income Statement

and Statement of Cash Flows

Check the box to confirm that the carrier’s balance sheet, income statement and statement of cash flows are provided as part of the document uploaded to Line 3017.

3017

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

Attach a copy of the annual RUS report.

3018

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

Indicate whether you carrier’s financial statements are audited.

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

Check the box to confirm that the carrier’s audited financial statement or a financial report in a format comparable to RUS Operating Report for Telecommunications Borrowers are provided as part of the document uploaded to Line 3026.

3020

Document(s) for Balance Sheet, Income Statement

and Statement of Cash Flows

Check this box to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains a Balance Sheet, Income Statement and Statement of Cash Flows.

3021

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

Check this box to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains a copy of a management letter and/or audit opinion issued by the independent certified public accountant that performed the company’s financial audit.

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

Check this box to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains a copy of your 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

Check this box to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains the underlying information subjected to a review by an independent certified public accountant.

3024

Underlying information subjected to an officer certification.

Check this box to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains the underlying information subjected to an officer certification

3025

Document(s) with Balance Sheet, Income Statement and Statement of Cash Flows.

Check this box to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains a Balance Sheet, Income Statement and Statement of Cash Flows.

3026

Attach the worksheet listing required information

Attach a worksheet which is compliant with the requirements if your company is a privately held RoR carrier that is not receiving loans from the RUS.

3027

Revenue

Enter the revenue amount included in the RUS report attached on line 3017 or the revenue amount included in the audited/reviewed financial statements attached on line 3026.

3028

Operating Expenses

Enter the operating expense amount included in the RUS report attached on line 3017 or the operating expense amount included in the audited/reviewed financial statements attached on line 3026.

3029

Net Income

Enter the net income amount included in the RUS report attached on line 3017 or the net income amount included in the audited/reviewed financial statements attached on line 3026.

3030

Telephone Plant in Service (TPIS)

Enter the TPIS amount included in the RUS report attached on line 3017 or the TPIS amount included in the audited/reviewed financial statements attached on line 3026.

3031

Total Assets

Enter the total assets amount included in the RUS report attached on line 3017 or the total assets amount included in the audited/reviewed financial statements attached on line 3026.

3032

Total Debt

Enter the total debt amount included in the RUS report attached on line 3017 or the total debt amount included in the audited/reviewed financial statements attached on line 3026.

3033

Total Equity

Enter the total equity amount included in the RUS report attached on line 3017 or the total equity amount included in the audited/reviewed financial statements attached on line 3026.

3034

Dividends

Enter the dividends amount included in the RUS report attached on line 3017 or the dividends amount included in the audited/reviewed financial statements attached on line 3026.

4001

Public Interest Obligations

Answer yes or no if any recipient of the RBE support offered broadband meeting the requisite public interest obligations consistent with the category for which they selected, including broadband speed, latency, usage capacity, and rates for comparable offerings in urban areas.

4003a

RBE Community Anchor Institutions

Indicate if the carrier newly deployed broadband service to community anchor institution(s) in the previous calendar year.

4003b

Please Provide Attachment

Using link, download template and list the number, name and address for each community anchor institution. Attach the document which contains the community anchor institution details as required by FCC 14-98 (paragraph 79).

5010

Do you participate in the Alaska plan?

Answer yes or no if the reporting carrier participates in the Alaska Plan.

5011

Newly Available Terrestrial or other Satellite Backhaul (RoR Carriers):

Answer yes or no whether any terrestrial backhaul or other satellite backhaul became commercially available in the previous calendar year in the areas previously served exclusively by performance-limiting satellite backhaul.

5012

Newly Available Terrestrial or other Satellite Backhaul (CETC Carriers):

Answer yes or no if any terrestrial backhaul or other satellite backhaul became commercially available in the previous calendar year in the areas that were previously served exclusively by satellite backhaul.

5013 (column a)

Description of Backhaul Technology:

Provide description of the backhaul technology.

5013 (column b)

Date Backhaul Available:

Provide date at which that backhaul was made commercially available to the carrier.

5013 (column c)

Newly Served Locations or Population:

Provide the number of locations (RoR participants) or the number of population (CETC participants) that are newly served by the new terrestrial backhaul or other satellite backhaul.

6010

Total amount of Phase II Auction support, if any, the Phase II Auction or New York recipient carrier used for capital expenditures in the previous calendar year

Enter the total amount of Phase II Auction Support, if any, the carrier used for capital expenditures.

6011

Phase II Auction and New York Available Funds Certification

Certify (either yes or no) regarding whether the recipient has available funds for all project costs that will exceed the amount of support that will be received for the next calendar year. This certification must be provided starting the first July 1st after receiving support until the recipient’s penultimate year of support.

6012a

Phase II Auction Community Anchor Institutions

Indicate if the carrier newly deployed broadband service to community anchor institution(s) in the previous calendar year.

6012b

Please Provide Attachment

Using link, download template and list the number, name and address for each community anchor institution. Attach the document which contains the community anchor institution details as required by 47 C.F.R. § 54.313(e)(2)(i)(A).

6013

Phase II Auction FCC Form 470 Postings

For the filing due July 1 following full implementation of this requirement answer yes, no, or not applicable to this certification request.

6014

Phase II Auction Post-Final Deployment Milestone Performance Certification

Starting the first July 1st after meeting the final service milestone, certify (yes or no) that the Phase II-funded network that the Phase II auction recipient operated in the prior year meets the relevant performance requirements in § 54.309.

7010

Price Cap Carrier and Fixed Competitive Eligible Telecommunications Carrier Transitional support requirement certification

Starting July 1, 2020 and for each subsequent year they receive such support, answer yes or no, that all such support the company received in the previous year was used to provide voice service throughout the high-cost and extremely high-cost census blocks where they continue to have the federal high-cost eligible telecommunications carrier obligation to provide voice service pursuant to §54.201(d) at rates that are reasonably comparable to comparable offerings in urban areas.

8010

Uniendo a Puerto Rico Stage 2 Fixed – Capital Expenditures

Enter the total amount of Uniendo a Puerto Rico Stage 2 fixed support, if any, the carrier used for capital expenditures.

8011

Uniendo a Puerto Rico Stage 2 Fixed – Available Funds Certification

Certify (either yes or no) regarding whether the recipient has available funds for all project costs that will exceed the amount of support that will be received for the next calendar year. This certification must be provided starting the first July 1st after receiving support until the recipient’s penultimate year of support.

8012a

Uniendo a Puerto Rico Stage 2 Fixed – Community Anchor Institutions

Indicate if the carrier newly deployed broadband service to community anchor institution(s) in the previous calendar year.

8012b

Please Provide Attachment

Using link, download template and list the number, name and address for each community anchor institution. Attach the document which contains the community anchor institution details as required by 47 C.F.R. § 54.313(e)(2)(i)(A).

8013

Uniendo a Puerto Rico Stage 2 Fixed – FCC Form 470 Postings

For the filing due July 1 following full implementation of this requirement answer yes, no, or not applicable to this certification request.

8014

Uniendo a Puerto Rico Stage 2 Fixed – Post-Final Deployment Milestone Performance Certification

Starting the first July 1st after meeting the final service milestone, certify (yes or no) that the Uniendo a Puerto Rico Stage 2-funded network that the Stage 2 recipient operated in the prior year meets the relevant performance requirements in § 54.309.

8020

Uniendo a Puerto Rico Stage 2 Fixed –Support Reimbursement Certification

All Stage 2 Support recipients must certify that support was not used for costs that are (or will be) reimbursed by other sources of support. Answer yes or no if reporting carrier is compliant with 54.313(n).

8030

Uniendo a Puerto Rico Stage 2 Fixed – Disaster Preparedness and Response Documentation

All Stage 2 support recipients must update their Disaster Preparation and Response Plan when they make material changes to internal processes or responsible staff and share the updated Disaster Preparation and Response Plan with the Bureau within 10 business days. Support recipients are also required to certify annually to USAC that they have recently reviewed the Disaster Preparation and Response Plan and considered whether any changes or revisions were necessary. Answer yes or no if carrier is compliant with 54.313(n) as required by 54.1515(a)-(c).

8040

Uniendo a Puerto Rico Stage 2 Mobile – Support Reimbursement Certification

All Stage 2 Support recipients must certify that support was not used for costs that are (or will be) reimbursed by other sources of support. Answer yes or no if reporting carrier is compliant with 54.313(n).

8050

Uniendo a Puerto Rico Stage 2 Mobile –Disaster Preparedness and Response Documentation

All Stage 2 support recipients must update their Disaster Preparation and Response Plan when they make material changes to internal processes or responsible staff and share the updated Disaster Preparation and Response Plan with the Bureau within 10 business days. Support recipients are also required to certify annually to USAC that they have recently reviewed the Disaster Preparation and Response Plan and considered whether any changes or revisions were necessary. Answer yes or no if carrier is compliant with 54.313(n) as required by 54.1515(a)-(c).

8060

Uniendo a Puerto Rico Stage 2 Mobile – Mobile Disbursements Certification

Recipients of Uniendo a Puerto Rico Fund Stage 2 mobile support must certify compliance with all requirements for receipt of such support to continue receiving Stage 2 mobile disbursements. Answer yes or no if carrier is compliant with 54.313(o).

9010

Connect USVI Fund Stage 2 Fixed - Capital Expenditures

Enter the total amount of Connect USVI Fund Stage 2 fixed support, if any, the carrier used for capital expenditures.

9011

Connect USVI Fund Stage 2 Fixed - Available Funds Certification

Certify (either yes or no) regarding whether the recipient has available funds for all project costs that will exceed the amount of support that will be received for the next calendar year. This certification must be provided starting the first July 1st after receiving support until the recipient’s penultimate year of support.

9012a

Connect USVI Fund Stage 2 Fixed – Community Anchor Institutions

Indicate if the carrier newly deployed broadband service to community anchor institution(s) in the previous calendar year.

9012b

Please Provide Attachment

Using link, download template and list the number, name and address for each community anchor institution. Attach the document which contains the community anchor institution details as required by 47 C.F.R. § 54.313(e)(2)(i)(A).

9013

Connect USVI Fund Stage 2 Fixed - FCC Form 470 Postings

For the filing due July 1 following full implementation of this requirement answer yes, no, or not applicable to this certification request.

9014

Connect USVI Fund Stage 2 Fixed -Post-Final Deployment Milestone Performance Certification

Starting the first July 1st after meeting the final service milestone, certify (yes or no) that the Connect USVI Fund Stage 2-funded network that the Stage 2 recipient operated in the prior year meets the relevant performance requirements in § 54.309.

9020

Connect USVI Fund Stage 2 Fixed -Support Reimbursement Certification

All Stage 2 Support recipients must certify that support was not used for costs that are (or will be) reimbursed by other sources of support. Answer yes or no if reporting carrier is compliant with 54.313(n).

9030

Connect USVI Fund Stage 2 Fixed -Disaster Preparedness and Response Documentation

All Stage 2 support recipients must update their Disaster Preparation and Response Plan when they make material changes to internal processes or responsible staff and share the updated Disaster Preparation and Response Plan with the Bureau within 10 business days. Support recipients are also required to certify annually to USAC that they have recently reviewed the Disaster Preparation and Response Plan and considered whether any changes or revisions were necessary. Answer yes or no if carrier is compliant with 54.313(n) as required by 54.1515(a)-(c).

9040

Connect USVI Fund Stage 2 Mobile - Support Reimbursement Certification

All Stage 2 Support recipients must certify that support was not used for costs that are (or will be) reimbursed by other sources of support. Answer yes or no if reporting carrier is compliant with 54.313(n).

9050

Connect USVI Fund Stage 2 Mobile - Disaster Preparedness and Response Documentation

All Stage 2 support recipients must update their Disaster Preparation and Response Plan when they make material changes to internal processes or responsible staff and share the updated Disaster Preparation and Response Plan with the Bureau within 10 business days. Support recipients are also required to certify annually to USAC that they have recently reviewed the Disaster Preparation and Response Plan and considered whether any changes or revisions were necessary. Answer yes or no if carrier is compliant with 54.313(n) as required by 54.1515(a)-(c).

9060

Connect USVI Fund Stage 2 Mobile - Mobile Disbursements Certification

Recipients of Connect USVI Fund Stage 2 mobile support must certify compliance with all requirements for receipt of such support to continue receiving Stage 2 mobile disbursements. Answer yes or no if carrier is compliant with 54.313(o).


Certification to be completed by a reporting carrier, if the carrier is filing annual reporting on its own behalf.



Name of Reporting Carrier

Provide the reporting carrier identification of the Study Area contained in this Form 481 filing.


Signature of the Authorized Officer

Provide the signature of the reporting carrier’s appropriate officer attesting to this Form 481 filing.


Date

Provide the date the reporting carrier’s appropriate officer executed this certification for this Form 481 filing.


Printed name of Authorized Officer

Provide the name of the reporting carrier’s appropriate officer who executed this certification for this Form 481 filing.


Title or position of the Authorized Officer

Provide title of the reporting carrier’s appropriate officer who executed this certification for this Form 481 filing.


Telephone number of Authorized Officer

Provide the telephone number of the reporting carrier’s appropriate officer who executed this certification for this Form 481 filing.


Study Area Code of Reporting Carrier

Provide the SAC identification code of the Study Area contained in this Form 481 filing.


Certification of an officer to authorize an agent to file annual reports on behalf of the reporting carrier



Name of Authorized Agent

Provide the name of the designated agent who will be executing the compliance filing on the reporting carrier’s behalf.


Name of Reporting Carrier

Provide the reporting carrier identification of the Study Area contained in this Form 481 filing.


Signature of Authorized Officer

Provide the signature of the reporting carrier’s appropriate officer attesting to this Form 481 filing.


Date

Provide the date the reporting carrier’s appropriate officer executed this certification for this Form 481 filing.


Printed Name of Authorized Officer

Provide the name of the reporting carrier’s appropriate officer who executed this certification for this Form 481 filing.


Title or position of Authorized Officer

Provide the title of the reporting carrier’s appropriate officer who executed this certification for this Form 481 filing.


Telephone number of Authorized Officer

Provide the telephone number of the reporting carrier’s appropriate officer who executed this certification for this Form 481 filing.


Study Area Code of Reporting Carrier

Provide the SAC identification code of the Study Area contained in this Form 481 filing.


Certification of agent authorized to file annual reports on behalf of the reporting carrier



Name of Reporting Carrier

Provide the reporting carrier identification of the Study Area contained in this Form 481 filing.


Name of the Authorized Agent Firm

Provide the name of the authorized agent firm who completed the compliance filing on the reporting carrier’s behalf.


Signature of Authorized Agent or Employee of Agent:

Provide the signature of designated agent, or their employee, who completed this Form 481 filing on the reporting carrier’s behalf.


Date

Provide the date the designated agent, or their employee executed this certification for this Form 481 filing.


Name of Authorized Agent Employee

Provide the name of the agent firm’s employee who executed this certification for this Form 481 filing.


Title or position of Authorized Agent or Employee of Agent

Provide the title of the reporting carrier’s designated agent, or its employee who executed this certification for this Form 481 filing.


Telephone number of Authorized Agent or Employee of Agent

Provide the telephone number of the reporting carrier’s designated agent, or its employee who executed this certification for this Form 481 filing.


Study Area Code of Reporting Carrier:

Provide the SAC identification code of the Study Area contained in this Form 481 filing (same as line 010).


Filing Due Date for This Form

Provide the date of when the current filing of this form is due.


Certify Filing Screen





Supply Chain Certification

Answer yes or no if the reporting carrier is compliant with § 54.9(a). If no, carrier must provide a PDF copy of the waiver of § 54.9 granted by the FCC, or a PDF copy of the pending waiver request submitted to the FCC.



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AuthorAnissa Qudsia
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