FCC Form 507 (Horizontal)

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FCC Form 507
Connect America Fund-Broadband Loop Support Mechanism
Line Count Report

FCC Form 507
OMB Control No. 3060-0986

LINE COUNT DATA COLLECTION
Block 1 - Contact Information
ROW #

DATA ELEMENT

FORMAT OF REQUESTED
DATA

1

Carrier Study Area Code

6 numeric digits

2

Carrier Study Area Name

alpha characters

3

Service Provider Identification Number

9 numeric digits

4

Data As Of

mm/dd/yyyy

5

Contact Name

alpha characters

Contact Telephone Number [including
6
area code]
7
Contact Email address
Block 2 - Line Counts

NO. OF ACQUIRED
LINES

10 numeric digits
alpha/numeric characters

8

Residential and Single-Line Business
Access Lines in Service

numeric digits

9

Multi-Line Business Access Lines in
Service

numeric digits

10

Consumer Broadband-Only Lines in
Service

numeric digits

11

Total Number of Lines in Service in
Study Area

numeric digits

12

Name of Carrier From Which Lines Were
Acquired, If Applicable
alpha characters

13

Study Area Code From Which Lines
Were Acquired, If Applicable

LINE COUNT REPORT

RESPONSE

6 numeric digits

Revised July 2016

FCC Form 507
FCC Form 507
OMB Control No. 3060-0986
Connect America Fund-Broadband Loop Support Mechanism
Line Count Report

TO BE COMPLETED BY THE REPORTING CARRIER, IF THE REPORTING CARRIER IS FILING FCC FORM 507 ON ITS OWN BEHALF:

Certification of Officer or Employee as to the Accuracy of the Data Reported in FCC Form 507, Line Count Report for
Connect America Fund, on Behalf of Reporting Carrier

I certify that I am an officer or employee of the reporting carrier; my responsibilities include ensuring the accuracy of the actual line
count data reported on FCC Form 507; and, to the best of my knowledge, the information reported on this form is accurate.

Name of Reporting Carrier
Signature of authorized officer or employee

Date

Printed name of authorized officer or employee
Title or position of authorized officer or employee
Email address of authorized officer or employee
Telephone number of authorized officer or employee: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _
Study Area Code of Reporting Carrier

Filing Due Date for this form
(mm/dd/yyyy)

Persons willfully making false statements on this form can be punished by fine or forfeiture under the Communications Act of 1934, 47 U.S.C. §§
502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. § 1001.

CERTIFICATION-REPORTING CARRIER

Revised July 2016

FCC Form 507
FCC Form 507
Connect America Fund-Broadband Loop Support Mechanism
OMB Control No. 3060-0986
Line Count Report
TO BE COMPLETED BY THE REPORTING CARRIER, IF AN AGENT IS FILING FCC FORM 507 ON THE CARRIER'S BEHALF:

Certification of Officer or Employee to Authorize an Agent to File FCC Form 507, Line Count Report for Connect
America Fund, on Behalf of Reporting Carrier
I certify that (Name of Agent)_______________________________________________________ is authorized to submit the
information reported on FCC Form 507 on behalf of the reporting carrier. I also certify that I am an officer or employee of the
reporting carrier; my responsibilities include ensuring the accuracy of the actual line count data provided to the authorized
agent; and, to the best of my knowledge, the actual line count data provided to the authorized agent is accurate.
I certify that I am authorized to submit the information reported on this form on behalf of the reporting carrier; that I have
provided the information reported herein based on data provided by the reporting carrier; and to the best of my knowledge the
information reported herein is accurate.
Name of Authorized Agent
Name of Reporting Carrier
Signature of authorized officer or employee

Date

Printed name of authorized officer or employee
Title or position of authorized officer or employee
Email address of authorized officer or employee
Telephone number of authorized officer or employee: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _
Study Area Code of Reporting Carrier

Filing Due Date for this form
(mm/dd/yyyy)

Persons willfully making false statements on this form can be punished by fine or forfeiture under the Comunications Act of 1934, 47 U.S.C.
§§ 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. § 1001.

TO BE COMPLETED BY THE AUTHORIZED AGENT:

Certification of Agent Authorized to File FCC Form 507, Line Count Report for Connect America Fund-Broadband
Loop Support Mechanism, on Behalf of Reporting Carrier
I, as agent for the reporting carrier, certify that I am authorized to submit the information reported on FCC Form 507 on behalf of
the reporting carrier; I have provided the line count data reported herein based on actual line count data provided by the
reporting carrier; and, to the best of my knowledge, the information reported herein is accurate. I also certify that I will provide
copies of the line count filing to the reporting carrier within 15 days.

Name of Reporting Carrier
Name of Authorized Agent
Signature of authorized agent or employee of agent

Date

Printed name of authorized agent or employee of agent
Title or position of authorized agent or employee of agent
Email address of authorized agent or employee of agent
Telephone number of authorized agent: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _
Study Area Code of Reporting Carrier

Filing Due Date for this form
(mmddyyyy)

Persons willfully making false statements on this form can be punished by fine or forfeiture under the Communications Act of 1934, 47
U.S.C. §§ 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. § 1001.

CERTIFICATION-AGENT

Revised July 2016

FCC Form 507
Connect America Fund-Broadband Loop Support Mechanism
Line Count Report

FCC Form 507
OMB Control No. 3060-0986

NOTICE: Sections 54.313(f)(5) and 54.903(a)(1) of the Federal Communications Commission's rules requires all rate-of-return telecommunications carriers
to provide line count information on FCC Form 507 to USAC, the universal service Administrator. Carriers receiving Connect America Fund Broadband
Loop Support (CAF BLS) must submit this information annually on March 31st of each year. Carriers that receive Alternative Connect America Model (ACAM) I, A-CAM II, or Alaska Plan support are required to file by July 1st 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 monitor and analyze
high-cost universal service programs.
We have estimated that each response to this collection of information will take, on average, 6.00 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 3060-0233.
The Commission is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. 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.
If you do not provide the information we request on this form, you are not eligible to receive support under the Connect America Fund 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.

NOTICE

Revised July 2016