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Instructions for Completing FCC Form 509 Connect America Fund-Broadband Loop Support Mechanism Annual CAF-BLS Actual Cost and Revenue Data Collection Form

FCC Form 509 OMB Control No. 3060-0233

Estimated Average Burden Hours Per Response: 4.0 Hours

Instructions for Completing Connect America Fund-Broadband Loop Support

Actual Cost and Revenue Data Collection Form FCC Form 509

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NOTICE: Section 54.903(a)(4) of the Federal Communications Commission's rules requires each rate-of-return incumbent telecommunications carrier that receives Connect America Fund-Broadband Loop Support (CAF-BLS) or Interstate Common Line Support (ICLS) to provide actual cost and revenue data for the prior calendar year to the Universal Service Administrative Company (USAC). USAC uses this information to reconcile the amount of CAF-BLS or ICLS that each carrier received based on forecasted data. This information must be submitted on December 31^st of each year. This collection of information stems from the Commission's authority under Section 254 of the Communications Act of 1934, as amended, 47 U.S.C. § 254. The data in the form will be used to calculate and adjust the amount of support, if any, that each reporting carrier is eligible to receive from the CAF-BLS or ICLS mechanisms.

We have estimated that each response to this collection of information will take, on average, 4.0 hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form or response. If you have any comments on this 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 Project (3060-0233), Washington, D.C. 20554. We also will accept your comments via the Internet if you send them to [email protected]. Please DO NOT SEND COMPLETED DATA COLLECTION FORMS 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 Office of Management and Budget (OMB) control number. This collection has been assigned an OMB control number of 3060-0986.

The Commission is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. We will use the information that you provide to determine CAF-BLS amounts. If we believe there may be a violation or potential violation of a statute or a Commission regulation, rule, or order, your form may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order. In certain cases, the information in your form may be disclosed to the Department of Justice, court, or other adjudicative body when (a) the Commission; (b) any employee of the Commission; or (c) the United States government, is a party to a proceeding before the body or has an interest in the proceeding. In addition, information provided in or submitted with this form or in response to subsequent inquiries may also be subject to disclosure consistent with the Communications Act of 1934, FCC regulations, the Freedom of Information Act, 5 U.S.C.

§ 552, or other applicable law. Confidential treatment of the filed data may be requested in the cover letter by following the procedures set forth in Section 0.459 of the Commission’s rules, 47 C.F.R. § 0.459.

If you do not provide the information we request on this form, you are not eligible to receive any support under the CAF- BLS mechanism, 47.C.F.R. § 54.903.

The foregoing Notice is required by the Paperwork Reduction Act of 1995, P.L. No. 104-13, 44 U.S.C. § 3501, et seq.

Specific Instructions

1. Introduction and Background.

In the MAG Order (FCC 01-304), the Federal Communications Commission (FCC) modified its rules to reform the interstate access charges and created Interstate Common Line Support (ICLS) for incumbent local exchange carriers subject to rate-of-return regulation. In the Rate-of-Return Reform Order (FCC 16-33), the FCC modified ICLS to support the provision of broadband service to consumers in areas with high loop-related costs, without regard to whether the loops are also used for traditional voice services, and renamed it Connect America Fund-Broadband Loop Support (CAF-BLS). Rate-of-return carriers will use FCC Form 509 to report actual cost and revenue data for CAF-BLS, as instructed below. The FCC appointed the Universal Service Administrative Company (USAC) as Administrator of this universal service support mechanism.

2. The Carrier or the Carrier’s Agent May File This Form.

You may choose to complete FCC Form 509 and submit it to USAC. Alternatively, you may choose to designate an agent to file FCC Form 509 on your behalf. Please note that, if you choose to designate an agent to complete and submit FCC Form 509 on your behalf, an authorized officer or employee of your company must advise USAC of the identity of your agent and certify that the annual CAF-BLS or ICLS actual cost and revenue data provided to your authorized agent is accurate to the best of his/her knowledge. Your authorized agent must: (1) certify that he/she is authorized to submit the information on behalf of the reporting carrier; (2) certify that the annual CAF-BLS or ICLS actual cost and revenue data provided on the form is based on data received from the reporting carrier; (3) certify that the information on the form is accurate to the best of the agent’s knowledge; and (4) provide copies of the annual CAF-BLS or ICLS actual cost and revenue data collection form to the reporting carrier within 15 days of the filing date. Specific instructions for complying with these steps are set forth below in Section V. Certifications.

3. When Must Each Rate-of-Return Incumbent Carrier File FCC Form 509 Annual CAF- BLS Actual Cost and Revenue Data Collection Form?

On December 31, 2016, and on that date each year thereafter, each rate-of-return incumbent carrier must file actual common line cost data for the preceding calendar year. 47 C.F.R. Section 54.903(a)(4).

Filing Due Date for Actual Results of Operations—Common Line Information	Reporting Period for Data
December 31	January 1 through December 31 of preceding year

USAC will use this actual cost and revenue data to reconcile the CAF-BLS that the carrier had receive in the prior calendar year based on projected cost and revenue data. To the extent that there are variances between the amount of CAF-BLS provided based on the projected cost and revenue data and the amount the carrier should have received based on actual cost and revenue data, true-ups will be applied during the following July 1 to June 30 funding year. For example, for true ups associated with calendar year 2017 will be calculated using actual data filed on December 31, 2018 and will be applied to disbursements from July 1, 2019 through June 30, 2020.

The filing due date of December 31st means that the annual CAF-BLS actual cost and revenue data collection form must be received by USAC on that date. 47 C.F.R. Section 54.903(a)(4).

4. Specific Instructions for Completing This Form.

Block 1 - Contact Information.

Row 1, Carrier Study Area Code: Provide your six-digit numerical code assigned by the National Exchange Carrier Association (NECA) for the study area in which you serve.

Row 2, Carrier Study Area Name: Provide the standard name that you use to identify your study area.

Row 3, Service Provider Identification Number: Provide the nine-digit Service Provider Identification Number (SPIN) that USAC has assigned to you. If you do not know your SPIN, please contact the HCLI Customer Service Center for assistance. Contact information for the HCLI Customer Service Center can be found in Section VIII of these instructions.

Row 4, Data Period: Provide the month, day, and year of the start date and end date for the period for which you have reported information in this form. This is the calendar year preceding the date on which the form is filed. For example, the annual CAF-BLS actual cost and revenue data collection form filed on December 31, 2017 must report information for the 2016 calendar year, January 1, 2016 through December 31, 2016. You would enter 01/01/ 2016 - 12/31/ 2016 for the CAF-BLS actual cost data that you report when you complete this form.

Row 5, Submission Date: Provide the month, day, and year of the submission date of the form. The CAF BLS actual cost and revenue data collection form is due annually on December 31.

Row 6, Contact Name: Provide the name of the person that USAC should contact to discuss any questions concerning the information that you submitted in this form.

Row 7, Contact Telephone Number: Provide the telephone number (including area code) of the person that you identified in Row 6.

Row 8, Contact E-mail Address: Provide the e-mail address of the person that you identified in Row 6.

Row 9, Annual Common Line Costs: Provide your actual annual Common Line Revenue Requirement in dollars, as defined in Part 69 of the FCC’s rules, for the reporting period.

Row 10, Annual Consumer Broadband-Only Loop Costs: Provide your actual annual Consumer Broadband-only Loop Revenue Requirement in dollars, as defined in Part 69 of the FCC’s rules, for the reporting period. If the data reported on this form relates to a period prior to January 1, 2017, then enter 0.

Row 11, Annual SLC Revenues: Provide your actual amount of Subscriber Line Charge (SLC) revenues in dollars that you collected, or would have collected if you charged the maximum allowable SLC rate, for the reporting period. 47 C.F.R. Sections 69.104(n) and 69.104(o).

Row 12a, Average Monthly Broadband-Only Loops: Provide your average Monthly Consumer Broadband-Only Loop for the reporting period. 47 C.F.R Section 54.901. If the data reported on this form relates to a period prior to January 1, 2017, then enter 0.

Row 12b, Multiply Row 12a by 12 months and by the revenue imputation of $42. 47 C.F.R. Section 54.901. If the data reported on this form relates to a period prior to January 1, 2017, then enter 0.

Row 12c, Provide the lesser of Row 10 or Row 12b. 47 C.F.R. Section 54.901. If the data reported on this form relates to a period prior to January 1, 2017, then enter 0.

Row 12d, Provide the Blended Average of Consumer Broadband-Only rates charged during time period pursuant to Section 69.132. The blended average rate should be weighted by the number of Consumer Broadband-only Loops in service at the time rates were in effect. If the data reported on this form relates to a period prior to January 1, 2017, then enter 0.

Row 12e, Multiply Row 12d by Row 12a and by 12 months. 47 C.F.R Section 54.901. If the data reported on this form relates to a period prior to January 1, 2017, then enter 0.

Row 12, Annual Consumer Broadband-Only Loop Revenues: Provide the greater of Row 12c or Row 12e. 47 C.F.R Section 54.901. This is the amount of Consumer Broadband-only Loop revenues that will be imputed for reporting period. If the data reported on this form relates to a period prior to January 1, 2017, then enter 0.

Row 13, Annual Special Access Surcharge Revenues: Provide your total amount of special access surcharge revenues in dollars that you collected for the reporting period. 47 C.F.R. Section 69.115.

Row 14, Annual Line Port Costs In Excess Of Basic Analog Service: Provide your total amount of line port costs in excess of basic analog service revenue in dollars that you collected during the reporting period. 47 C.F.R. Section 69.130.

5. Certifications.

You must submit certifications with the signature of an authorized person with the FCC Form 509.

If you are filing FCC Form 509 on your own behalf, you must complete the reporting carrier certification page. If you are authorizing an agent to file FCC Form 509 on your behalf, on the other hand, you must complete the top portion of the agent certification page. Once you have completed the top portion of the agent certification page, your authorized agent must complete the bottom portion of the agent certification page.

Carriers submitting FCC Form 509 on their own behalf. If you are filing FCC Form 509 on your own behalf, an authorized officer or employee of your company must complete the reporting carrier certification page of FCC Form 509. By completing the reporting carrier certification page, the officer or employee of the reporting carrier is certifying that: (1) he/she is an officer or an employee of the reporting carrier; (2) his/her responsibilities include ensuring the accuracy of the annual common line actual cost and revenue data reported on the form; (3) the cost data is compliant with the Commission's cost allocation rules and does not reflect duplicative assignment of costs to the consumer broadband-only loop and special access categories; and (4) the information reported on the form is accurate to the best of his/her knowledge. The certification must be signed by an authorized officer or employee of the company and must be submitted to USAC along with the annual CAF-BLS actual cost and revenue data collection worksheet.

Carriers authorizing an agent to file FCC Form 509 on their behalf. If you are authorizing an agent to file FCC Form 509 on your behalf, you, as the reporting carrier, must complete the top portion of the agent certification page of FCC Form 509. By completing the agent authorization section, the officer or employee of your company is certifying that: (1) the agent identified on the agent certification is authorized to submit the annual CAF-BLS actual cost and revenue data to USAC on your behalf; (2) he/she is an officer or employee of the reporting carrier; (3) his/her responsibilities include ensuring the accuracy of the annual CAF-BLS actual cost and revenue data provided to the authorized agent; (4) the cost data is compliant with the Commission's cost allocation rules and does not reflect duplicative assignment of costs to the consumer broadband-only loop and special access categories; and (5) the annual CAF-BLS actual cost and revenue data provided to the authorized agent is accurate to the best of his/her knowledge. The certification must be signed by an authorized officer or employee of the company. You will then provide the certification with the signature of the authorized person to your authorized agent.

Your authorized agent is responsible for completing the bottom portion of the agent certification page of FCC Form 509. By completing the agent certification section, the authorized agent is certifying that: (1) he/she is authorized to submit the information on your behalf; (2) the annual CAF BLS actual cost and revenue data provided on the form is based on data received from you (the reporting carrier); (3) the information provided on the form is accurate to the best of the agent’s knowledge; and (4) the authorized agent will provide copies of the annual CAF BLS actual cost and revenue data collection form to you within 15 days of the filing date. The certification must be signed by the authorized agent or an employee of the authorized agent.

Certifications with the signatures of the authorized persons, as well as all of the information requested on the worksheet of FCC Form 509 for all incumbent rate-of-return carriers, must be received by USAC in accordance with the filing dates on pages 2 and 3 of these instructions.

Please remember that, if the form is submitted electronically in Excel 97 or above, the certifications with the signatures of the authorized persons still must be received by USAC by the due dates.

6. Request for Confidential Treatment of Filed Data.

You may request confidential treatment of some or all of the data filed to qualify for CAF BLS by making such a request in your cover letter transmittal of your FCC Form 509 and by complying with the requirements set forth in 47 C.F.R. Section 0.459.

7. Where to File Completed Forms.

You are encouraged to submit the form electronically via email at [email protected] . The form must be received at the address listed below by the due date. If you are unable to submit the completed form in electronic format, please submit your paper copies to the same address.

U.S. Mail, Overnight, or Expedited Mail/Courier Services:

USAC

Customer Operations

700 12^th Street, NW

Suite 900

Washington, DC 20005

(844) 357-0408

8. If You Have Questions.

Please consult the USAC Web site, ^{https://www.usac.org/hc/} for important information and updates.

You may submit questions via e-mail to [email protected]

You may telephone USAC’s HC Customer Service Center at (844) 357-0408 (toll-free).

When submitting any inquiry to USAC’s HC Customer Service Center, whether by telephone or e-mail , please provide the name of the person submitting the inquiry and the company on whose behalf the inquiry is submitted, the person’s telephone number, e-mail address, and please describe your inquiry as specifically as possible.

Revised January 2023