State, Local or Tribal Government

Non-Public OMB XXXX-XXXX

High Cost Universal Service

Information to be Submitted to Online Eligible Locations Adjustment Process (ELAP) Portal

(Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual representation of what each applicant will see).

Participant Information

Item Number	Description	Purpose/Instructions
1	Participant Name	Name of the authorized support recipient participating in this process.
2	Participant Address(s)	Address (Primary, Secondary (and Address for Service of Process, if Different from Primary). Autogenerated.
3	Data Contact Name(s)	Name(s) of person(s) who prepared the submitted information for each filing type, i.e., location data, methodology, and supporting evidence.
4	Data Contact Phone Number(s)	Phone number(s) of Data Contact(s)
5	Data Contact Phone Number(s) extension	Phone number extension, if any, of Data Contact(s).
6	Data Contact E-mail address(es)	Email address(es) of Data Contact(s).
7	Study Area Code(s)	Study Area code associated with location.
8	State	State associated with location.
9	Census Block Code	Census block code associated with location. Autogenerated.
10	Latitude of Location	Latitude of reported location.
11	Longitude of Location	Longitude of reported location.
12	Location Address – Number & Street (Postal)	Number and street address of location.
13	Location Address-City	City associated with the street address of location.
14	Location Address-State	Two letter postal abbreviation of the state associated with the street address of location.
15	Location Address-Zip Code	Five-digit ZIP code associated with the street address of location.
16	Location Address-No Postal Physical Address Available	In those cases where no postal physical address (line 12) is available, alternate address information.
17	Number of units	If the location is a building with multiple units, such as an apartment or office building, the number units at that location.
18	Global Positioning System (GPS) Method	Primary method (i.e., field research, computer-based geolocation, or automated address geolocation) used to geolocate location.
19	GPS Method as of Date	Date that field research or underlying research for computer-based or automated address geolocation method was last confirmed as accurate.
20	Location Type	Type of location reported, i.e., 1) qualifying location, 2) prospective location, 3) ineligible location.
21	Ineligible Reason Code	Identifies reason why specified location is marked ineligible, i.e., 1) Empty Parcel/Under Development; 2) Group Quarters; 3) Permanently Vacant; 4) Community Anchor Institution; 5) Recreational or other non-residential, structure; 6) Storage or Agricultural use structure; 7) Other.
22	Ineligible Reason Comment	Further explanation if participant selects “7) other” (item 21) as Ineligible Reason Code.
23	Methodology for Identifying Eligible Locations	Narrative description of methodology or methodologies used to identify all eligible locations within the state.
24	Supporting Evidence	Evidence supporting description of methodology and identification of locations, e.g., copies of (or links to) web-based photography, database pages, and/or public records information for a sample of randomly selected land units (i.e., parcels, plots).
25	Officer Certification	Officer certification that ELAP information is true and correct.
26	Certifying Official Name	Name of certifying official.
27	Certifying Official Title	Job title of certifying official.
28	Date Signed	The date on which the filing is certified. Auto-generated.

Prospective Stakeholder Information to Confirm Identity and Eligibility

Item Number	Description	Purpose/Instructions
1	Contact Person Name	Name of person (First, Middle, Last) entering information to confirm identity and eligibility of prospective stakeholder.
2	Contact Person Title	Title of the Contact Person.
3	Identification of Category of Prospective Stakeholder	Type of entity that is seeking a determination of eligibility to participate in ELAP as a stakeholder, e.g., Individual; Commercial Entity; Non-Profit Entity; Non-Governmental Federal Agency.
4	Prospective Stakeholder Address(es) (Physical and Mailing)	Physical and Mailing Address(es) of Prospective Stakeholder for purposes of identification and contact.
5	Prospective Stakeholder Social Security Number (Last Four Digits Only)	Prospective Stakeholders that have been assigned a Social Security Number must submit the last four digits of this number.
6	Prospective Stakeholder Data Universal Number System (DUNS)	Prospective Stakeholders that are assigned (or are capable of being assigned a Data Universal Number System) must submit the number.
7	Prospective Stakeholder Taxpayer Identification Number (TIN)	Prospective Stakeholders that have been assigned a Taxpayer Identification Number (TIN) must submit the number.
8	Prospective Stakeholder Taxpayer Identification Number (ITIN)	Prospective Stakeholders that have been assigned a Taxpayer Identification Number (ITIN) must submit the number.
9	Address(es) (Physical and Mailing) of Prospective Stakeholder’s (individual or entity) Property and/or Commercial Interest(s) to be Verified.	Address(es) (Physical and Mailing) of Prospective Stakeholder’s (individual or entity) property and/or commercial Interest(s) to be verified. Physical Address: Number, Street Address, City, State (two-letter postal abbreviation), Zip Code (five digits).
10	Alternative Address Information for Prospective Stakeholder’s (individual or entity) Property and/or Commercial Interest(s) to be Verified-No Postal Physical Address Available	In those cases where physical address (line 9) is not available, alternate address information for property and/or commercial interests to be verified.
11	Description of Prospective Stakeholder’s (non-Federal governmental entities) Jurisdictional Areas	Description of geographic boundaries of non-Federal governmental agency’s jurisdictional area(s), e.g., county, state, reservation, etc.
12	Description of Interest(s) to be Verified	Description of Interest(s) to be verified, e.g., lessor, developer, resident, regulatory.
13	Alternative Information—Unable to Verify	Where verifier cannot confirm identity or interests based on the above fields, prospective stakeholder may submit, on a voluntary basis, alternative information.
14	Census Block Codes where Interests are Verified	The census block codes of the location(s) or area where the Prospective Stakeholder has established a verified interest in receiving broadband service. Auto-generated.
15	Acknowledgement of Privacy Act Notice.	Prospective Stakeholder acknowledgement of Privacy Act Notice.
16	Certification	Certification that the: 1) information submitted for purposes of verification is true and correct and 2) that the prospective stakeholder does not hold a controlling interest in a competitive provider of the relevant participant.
17	Certifier Name	Name of Certifier.
18	Certifier Title	Job title of Certifier.
19	Date Signed	The date on which Certification is made. Auto-generated.

Stakeholder Information for Challenge

Item Number	Description	Purpose/Instructions
1	Stakeholder Name	Name of the individual, entity, or non-Federal governmental agency, including any State or local government, or agency thereof. Auto-generated.
2	Stakeholder Address (Physical and Mailing)	Address (Physical and Mailing) of Stakeholder (as submitted to establish identity and eligibility). Auto-generated.
3	Data Contact Name(s)	Name(s) of the person(s) who prepared the submitted location information for each filing type, i.e., location data, methodology, and supporting evidence.
4	Data Contact Phone Number(s)	Phone number(s) of Data Contact(s).
5	Data Contact Phone Number(s) extension	Phone number extension(s), if any, of Data Contact(s).
6	Data Contact E-mail address(es)	Email address(es) of Data Contact(s).
7	Study Area Code(s)	Study Area code(s) applicable to data filed.
8	State	The state or states for which the carrier is making a filing.
9	Census Block Code	The census block code(s) of the location. Auto-generated based on submitted latitude/longitude of location.
10	Latitude of Location	Latitude of the reported location.
11	Longitude of Location	Longitude of reported location.
12	Location Address – Number & Street	Number and street address of the location.
13	Location Address-City	City associated with the street address of the location.
14	Location Address-State	Two letter postal abbreviation of the state associated with the street address of the location.
15	Location Address-Zip Code	Five-digit ZIP code associated with the street address of the location.
16	Location Address-No Postal Address Available	In those cases where physical address (line 12) is not available, alternate address information.
17	Number of units	If the location is a building with multiple units, such as an apartment or office building, the number units at that location.
18	GPS Method	Primary method (i.e., field research, computer-based geolocation, or automated address geolocation) used to geolocate reported location
19	GPS Method as off Date	Date that field research or underlying research for computer-based or automated address geolocation was last confirmed as accurate.
20	Location Type	Type of Location reported as per drop-down list: 1) qualifying location, 2) prospective location, 3) ineligible location.
21	Ineligible Reason Code	Explanation of why location was reported was “3) ineligible location,” (line 20) using preset drop-down list.
22	Ineligible Reason Comment	Further explanation if participant selects “other” (line 21) as reason code for marking location as ineligible.
23	Methodology for Identifying Eligible Locations	Narrative description (pdf) of methodology or methodologies used to identify all eligible locations within the state.
24	Supporting Evidence	Evidence supporting description of methodology and identification of locations, e.g., copies of (or links to) web-based photography, database pages, and/or public records information for a sample of randomly selected land units (i.e., parcels, plots).
25	Certification	Certification that all ELAP information is true and correct and that the stakeholder is eligible to participate in ELAP.
26	Certifier Name	Name of certifier. May be same as Data Contact Name (line 3).
27	Certifier Title	Title of certifier (must be an official) if Stakeholder is not an individual.
28	Certifier Phone Number	Phone number of the certifier. May be autogenerated from Data Contact(s) Phone Number (line 4).
29	Certifier Phone Number, Extension	Phone number extension of the certifier. May be autogenerated from Data Contact Phone Number Extension (line 5).
30	Certifier Email Address	Email address of the certifier. May be autogenerated from Data Contact(s) Official Email Address (line 6).
31	Date Signed	Date on which the filing is certified. Auto-generated.

13