FCC Form 481 Annual Reporting for High-Cost and Low-Income Universal

OMB Approval July 2022
Overview of FCC Form 481

OMB Control No. 3060-0986 (High-Cost)
Est. time per response 20 hours
OMB Control No. 3060-0819 (Low-Income)
Est. time per response 3 hours

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

020
030

Program Year
Contact Name

035

Contact Phone Number

039

Contact Email Address

210

Voice Telephony Service Outage Reporting

220 (column a)

NORS Reference Number

220 (column b1)

Outage Start Date

220 (column b2)

Outage Start Time

220 (column b3)
220 (column b4)
220 (column c1)

Outage End Date
Outage End Time
Number of Customers Affected

220 (column c2)

Total Number of Customers

220 (column d)

911 Facilities Affected (yes/no)

220 (column e)

Service Outage Description

220 (column f)

Did this Service Outage Affect Multiple Study Areas

220 (column g)

Service Outage Resolution

220 (column h)

Preventative Procedures

400

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

410

Complaints per 1000 customers for fixed voice

420

Complaints per 1000 customers for mobile voice

515

Certify compliance with applicable minimum service standards

600

Certify compliance regarding ability to function in emergency situations

010
015

Purpose/Instructions

Study Area Code (SAC)
Study Area Name

1

Study Area codes applicable to data filed.
The standard name used to identify your
study area. Typically the name is the same
as your company name.
The upcoming calendar year.
Name of the individual that prepared the
data submission for your company.
Telephone number of the individual that
prepared the data submission for your
company.
The email address of the individual that
prepared the data submission for your
company.
Respond with ‘yes’ or ‘no’ if there were any
reportable voice service outages in the prior
calendar year.
Reference number associated with the data,
for this outage incident, that was reported
on the Network Outage Reporting System.
Date of the onset of the service outage.
(format mm/dd/yyyy)
Time of the onset of the service outage.
(format: hh/mm)
Date of the end of the service outage.
Time of the end of the service outage.
Total number of customers affected at any
time during the service outage
Amount of the study area’s total customer
base.
Confirm whether the outage impacted the
911 facilities’ functionality at any time
during the service outage.
Provide which services were affected by the
service outage.
Answer yes or no if this service outage
affected multiple study areas.
Brief description of the processes used to
resolve the service outage.
Brief description of the preventative
procedures implemented by the carrier to
avoid the occurrence of a similar service
outage in the future.
Indicate the type(s) of voice services offered
in the service area for any facilities you own,
operate, lease, or otherwise utilize.
Number of Complaints per 1,000 customers
for voice (fixed).
Number of Complaints per 1,000 customers
for voice (mobile).
Indicate yes or no to certify for compliance
with applicable minimum service standards.
Answer yes or no to indicate that the carrier
is able function in emergency situations.

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

Field Description

810

Reporting Carrier

811 (a-d)

Holding Company

812

Operating Company

813 (column a1)

Affiliates

813 (column a2)
813 (column a3)

SAC
Doing Business As Company or Brand Designation

900

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

910

Tribal Land(s) on which ETC Serves

920

Tribal Government Engagement Obligation

921

Needs assessment and deployment planning with a focus on Tribal
Community anchor institutions.

922

Feasibility and sustainability planning;

923

Marketing services in a culturally sensitive manner

924

Compliance with Rights of way processes

925

Compliance with Land Use permitting requirements

926

Compliance with Facilities Siting rules

610

Descriptive document for Functionality in Emergency Situations

2

Purpose/Instructions

Attach a PDF that provides details of the
carrier’s preparedness to ensure continued
service during an emergency situation.
Name associated with the study area
reported in this document
Name of the corporate holding company
associated with the study area reported in
this document.
Name of the corporate operating company
designation associated with the study area
reported in this document.
Name of any corporate affiliates associated
with the study area reported In this
document.
SAC associated with the affiliate ETCs.
The alternate corporate branding or legal
“Doing Business As” designations associated
with the study area reported in this
document.
Answer Yes or No to indicate if the carrier
has Tribal Land offerings.
Name of Tribal Land(s) on which the carrier
provides service.
PDF that outlines discussions the carrier has
had with the Tribal governments.
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.
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.
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.
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 rightof-way processes for the Tribal lands.
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.
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.

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

Field Description

928

Compliance with Cultural Preservation review processes

929

Compliance with Tribal Business and Licensing requirements.

1000

Voice services rate comparability certification

1010

Attach detailed description for voice services rate
comparability compliance

1020

Broadband comparability certification

1030

Attach detailed description for broadband
comparability compliance

1100

Certify whether terrestrial backhaul options exist (Y/N)

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).

1140

Alaska Plan rate-of-return certification (yes, no, or not applicable) of
Compliance with approved performance plan.

927

Compliance with Environmental Review processes

3

Purpose/Instructions

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

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

Field Description

1220

Link to Public Website

1221

Information describing 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,

1223

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

2015

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

2016

Certification support used to build broadband

2017 (a)

Connect America Fund Phase II recipient?

2017 (c)

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

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)

2019

Connect America Phase II - FCC Form 470 Postings:

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?

3007a

Name(s) of Consultant/Third Party

3007b

Name(s) of Consultant Firm

1210

Terms & Conditions of Voice Telephony Lifeline Plans

4

Purpose/Instructions

Attach a document which details the terms
and conditions of any voice telephony
service plans.
Provide public website that details the
terms and conditions of any voice telephony
service plans.
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.
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.
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.
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.
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.
Answer yes or no if you are a CAF Phase II
Recipient.
Enter the total amount of Phase II Support,
if any, the carrier used for capital
expenditures.
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.
For the filing due July 1 following full
implementation of this requirement, answer
yes, no, or not applicable to this certification
request.
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.
Enter the name(s) of any cost consultant or
third party that helped in preparing the
disclosures or any financial data.
Enter the name(s) of the cost consultant
firm associated with the cost consultant
named in line 3007a.

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

Field Description

3010a

Certification of Public Interest Obligations

3010b

Please Provide Attachment

3012a

Rate-of-Return Community Anchor Institutions

3012b

Please Provide Attachment

3013

Is your company a Privately Held ROR Carrier

3014

If yes, does your company file the RUS annual report

3015

Electronic copy of their annual RUS reports
(Operating Report for Telecommunications
Borrowers)
Document(s) with Balance Sheet, Income Statement
and Statement of Cash Flows

3009

3016

3017
3018

Purpose/Instructions

Progress Report

If the response is yes on line 3014, attach your company's RUS annual
report and all required documentation
If the response is no on line 3014, is your company 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

3020

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

5

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.
Answer yes - attach certification, no – attach
explanation, or not applicable – no
attachment required, to indicate whether
this certification may be provided.
Attach a document either providing the
certification stated (if yes) or an explanation
of non-compliance (if no).
Indicate if the carrier newly deployed
broadband service to community anchor
institution(s) in the previous calendar year.
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).
Indicate whether your carrier is a privately
held Rate of Return carrier as defined in 47
CFR 54.313(f)(2)
Indicate whether your carrier files the RUS
annual report.
Check the box to confirm that a copy of the
RUS annual report is provided as part of the
document uploaded to Line 3017.
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.
Attach a copy of the annual RUS report.
Indicate whether you carrier’s financial
statements are audited.
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.
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.

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

Field Description

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

3023

Underlying information subjected to a review by an independent
certified public accountant

3024

Underlying information subjected to an officer certification.

3025

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

3026

Attach the worksheet listing required information

3027

Revenue

3028

Operating Expenses

3029

Net Income

3030

Telephone Plant in Service (TPIS)

3031

Total Assets

3032

Total Debt

3021

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

6

Purpose/Instructions

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.
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
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.
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
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.
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.
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.
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.
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.
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.
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.
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.

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

Field Description

3034

Dividends

4001

Public Interest Obligations

4003a

RBE Community Anchor Institutions

4003b

Please Provide Attachment

5010

Do you participate in the Alaska plan?

5011

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

5012

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

5013 (column a)

Description of Backhaul Technology:

5013 (column b)

Date Backhaul Available:

5013 (column c)

Newly Served Locations or Population:

3033

Purpose/Instructions

Total Equity

7

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.
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.
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.
Indicate if the carrier newly deployed
broadband service to community anchor
institution(s) in the previous calendar year.
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).
Answer yes or no if the reporting carrier
participates in the Alaska Plan.
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.
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.
Provide description of the backhaul
technology.
Provide date at which that backhaul was
made commercially available to the carrier.
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.

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

Field Description

5014b

Please Provide Attachment

6010
6011

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
Phase II Auction and New York Available Funds Certification

6012

Phase II Auction Community Anchor Institutions

6013

Phase II Auction FCC Form 470 Postings

6014

Phase II Auction Post-Final Deployment Milestone Performance
Certification

7010

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

8010

Uniendo a Puerto Rico Stage 2 Fixed - Capital Expenditures

5014a

Mobile carriers’ reasonably comparable rate demonstration, at the end
of their 5-year milestone:

8

Purpose/Instructions

Answer yes or no if mobile carriers receiving
support from the Alaska Plan can
demonstrate compliance at the end of the
five-year milestone (2022) by showing that
your required stand-alone voice plan, and
one service plan that offers broadband data
services, if you offer such plans, are:
(1) Substantially similar to a service plan
offered by at least one mobile
wireless service provider in the
cellular market area (CMA) for
Anchorage, Alaska, and
(2) Offered for the same or a lower rate
than the matching plan in the CMA
for Anchorage.
If ‘Yes’, attach a document demonstrating
compliance with the 5-year milestone. If
‘No’, attach an explanation of noncompliance.
Enter the total amount of Phase II Auction
Support, if any, the carrier used for capital
expenditures.
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.
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.
For the filing due July 1 following full
implementation of this requirement answer
yes, no, or not applicable to this certification
request.
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.
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.
Enter the total amount of Uniendo a Puerto
Rico Stage 2 fixed support, if any, the carrier
used for capital expenditures.

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

Field Description

8012a

Uniendo a Puerto Rico Stage 2 Fixed - Community Anchor Institutions

8012b

Please Provide Attachment

8013

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

8014

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

8020

Uniendo a Puerto Rico Stage 2 Fixed - Support Reimbursement
Certification

8030

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

8040

Uniendo a Puerto Rico Stage 2 Mobile - Support Reimbursement
Certification

8011

Uniendo a Puerto Rico Stage 2 Fixed - Available Funds Certification

9

Purpose/Instructions

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.
Indicate if the carrier newly deployed
broadband service to community anchor
institution(s) in the previous calendar year.
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).
For the filing due July 1 following full
implementation of this requirement answer
yes, no, or not applicable to this certification
request.
Starting the first July 1st after meeting the
final service milestone, certify (yes or no)
that the Uniendo a Puerto Rico Stage 2funded network that the Stage 2 recipient
operated in the prior year meets the
relevant performance requirements in §
54.309.
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).
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).
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).

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

Field Description

8060

Uniendo a Puerto Rico Stage 2 Mobile - Mobile Disbursements
Certification

9010

Connect USVI Fund Stage 2 Fixed - Capital Expenditures

9011

Connect USVI Fund Stage 2 Fixed - Available Funds Certification

9012a

Connect USVI Fund Stage 2 Fixed - Community Anchor Institutions

9012b

Please Provide Attachment

9013

Connect USVI Fund Stage 2 Fixed - FCC Form 470 Postings

9014

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

9020

Connect USVI Fund Stage 2 Fixed - Support Reimbursement
Certification

8050

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

10

Purpose/Instructions

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).
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).
Enter the total amount of Connect USVI
Fund Stage 2 fixed support, if any, the
carrier used for capital expenditures.
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.
Indicate if the carrier newly deployed
broadband service to community anchor
institution(s) in the previous calendar year.
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).
For the filing due July 1 following full
implementation of this requirement answer
yes, no, or not applicable to this certification
request.
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.
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).

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

Field Description

9040

Connect USVI Fund Stage 2 Mobile - Support Reimbursement
Certification

9050

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

9060

Connect USVI Fund Stage 2 Mobile - Mobile Disbursements
Certification

10010

Rural Digital Opportunity Fund - Capital Expenditures

10011

Rural Digital Opportunity Fund - Available Funds Certification

10012a

Rural Digital Opportunity Fund - Community Anchor Institutions

10012b

Please Provide Attachment

9030

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

11

Purpose/Instructions

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).
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).
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).
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).
Enter the total amount of Rural Digital
Opportunity Fund support, if any, the carrier
used for capital expenditures. This is
required by 47 C.F.R. § 54.313(e)(2)(i)(B).
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. This required
by 47 C.F.R. § 54.313(e)(2)(ii).
Indicate if the carrier newly deployed
broadband service to community anchor
institution(s) in the previous calendar year.
This is required by 47 C.F.R. §
54.313(e)(2)(i)(A).
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.

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

Field Description

10014

Rural Digital Opportunity Fund - Post-Final Deployment Milestone
Performance Certification

10013

Rural Digital Opportunity Fund - FCC Form 470 Postings

Certification to be completed by a reporting carrier, if the carrier is
filing annual reporting on its own behalf.
Name of Reporting Carrier
Signature of the Authorized Officer
Date
Printed name of Authorized Officer
Title or position of the Authorized Officer
Telephone number of Authorized Officer

Study Area Code of Reporting Carrier
Certification of an officer to authorize an agent to file annual reports
on behalf of the reporting carrier
Name of Authorized Agent
Name of Reporting Carrier
Signature of Authorized Officer
Date
Printed Name of Authorized Officer
Title or position of Authorized Officer
Telephone number of Authorized Officer

Study Area Code of Reporting Carrier
Certification of agent authorized to file annual reports on behalf of
the reporting carrier

12

Purpose/Instructions

For the filing due July 1 following full
implementation of this requirement answer
yes, no, or not applicable to this certification
request. This is required by 47 C.F.R. §
54.313(e)(2)(i)(C).
Starting the first July 1st after meeting the
final service milestone, certify (yes or no)
that the Rural Digital Opportunity Fundfunded network recipient operated in the
prior year meets the relevant performance
requirements in § 54.309.
Provide the reporting carrier identification
of the Study Area contained in this Form
481 filing.
Provide the signature of the reporting
carrier’s appropriate officer attesting to this
Form 481 filing.
Provide the date the reporting carrier’s
appropriate officer executed this
certification for this Form 481 filing.
Provide the name of the reporting carrier’s
appropriate officer who executed this
certification for this Form 481 filing.
Provide title of the reporting carrier’s
appropriate officer who executed this
certification for this Form 481 filing.
Provide the telephone number of the
reporting carrier’s appropriate officer who
executed this certification for this Form 481
filing.
Provide the SAC identification code of the
Study Area contained in this Form 481 filing.
Provide the name of the designated agent
who will be executing the compliance filing
on the reporting carrier’s behalf.
Provide the reporting carrier identification
of the Study Area contained in this Form
481 filing.
Provide the signature of the reporting
carrier’s appropriate officer attesting to this
Form 481 filing.
Provide the date the reporting carrier’s
appropriate officer executed this
certification for this Form 481 filing.
Provide the name of the reporting carrier’s
appropriate officer who executed this
certification for this Form 481 filing.
Provide the title of the reporting carrier’s
appropriate officer who executed this
certification for this Form 481 filing.
Provide the telephone number of the
reporting carrier’s appropriate officer who
executed this certification for this Form 481
filing.
Provide the SAC identification code of the
Study Area contained in this Form 481 filing.

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

Field Description

Purpose/Instructions

Name of Reporting Carrier
Name of the Authorized Agent Firm
Signature of Authorized Agent or Employee of Agent:

Date
Name of Authorized Agent Employee
Title or position of Authorized Agent or Employee of Agent

Telephone number of Authorized Agent or Employee of Agent

Study Area Code of Reporting Carrier:
Filing Due Date for This Form
Certify Filing Screen
Supply Chain Certification 54.9

Provide the reporting carrier identification
of the Study Area contained in this Form
481 filing.
Provide the name of the authorized agent
firm who completed the compliance filing
on the reporting carrier’s behalf.
Provide the signature of designated agent,
or their employee, who completed this
Form 481 filing on the reporting carrier’s
behalf.
Provide the date the designated agent, or
their employee executed this certification
for this Form 481 filing.
Provide the name of the agent firm’s
employee who executed this certification
for this Form 481 filing.
Provide the title of the reporting carrier’s
designated agent, or its employee who
executed this certification for this Form 481
filing.
Provide the telephone number of the
reporting carrier’s designated agent, or its
employee who executed this certification
for this Form 481 filing.
Provide the SAC identification code of the
Study Area contained in this Form 481 filing
(same as line 010).
Provide the date of when the current filing
of this form is due.
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.
Answer yes or no if the reporting carrier is
compliant with § 54.10. If no, carrier must
provide a PDF copy of the waiver of § 54.10
granted by the FCC, or a PDF copy of the
pending waiver request submitted to the
FCC.
Effective Q1 2023
Answer yes or no (I am participating in the
reimbursement program and the removal,
replacement, and disposal term has not
expired) if the reporting ETC does not use
covered communications equipment or
services published on the Covered List, as
required by 47 C.F.R. § 54.11.

Supply Chain Certification 54.10

Supply Chain Certification 54.11

13