Competitive Carrier Line Count Report and Self-Certification as a Rural Carrier

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Overview

RATE FLOOR REPORT
CERTIFICATION-REPORTING CARRIER
CERTIFICATION-AGENT

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Sheet 1: RATE FLOOR REPORT

RATE FLOOR DATA COLLECTION - OMB Control Number 3060-0986
Block 1 - Contact Information
ROW #	DATA ELEMENT			FORMAT OF REQUESTED DATA	RESPONSE
1	Carrier Study Area Code			6 numeric digits
2	Carrier Study Area Name			alpha characters
3	Service Provider Identification Number			9 numeric digits
4	Residential Local Service Charge Effective Date			mm/dd/yyyy
5	Contact Name			alpha characters
6	Contact Telephone Number (include area code)			9 numeric digits
7	Sheet number			numeric digit(s)
8	Total Number of Sheets			numeric digit(s)
Block 2 - Residential Local Service Rates, Fees, and Line Counts
	Column 1 Residential Local Service Charge	Column 2 State Subscriber Line Charge	Column 3 State Universal Service Fee	Column 4 Mandatory Extended Area Service Charge	Column 5 Loops
9
10
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12
13
14
15
16
17
18
19
20
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22
23
24
25
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34

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Sheet 2: CERTIFICATION-REPORTING CARRIER

TO BE COMPLETED BY THE REPORTING CARRIER, IF THE REPORTING CARRIER IS FILING RATE FLOOR DATA ON ITS OWN BEHALF:

Certification of Officer as to the Accuracy of the Data Reported for the Rate Floor Data

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

Telephone number of authorized officer or employee: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _

Study Area Code of Reporting Carrier

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

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Sheet 3: CERTIFICATION-AGENT

TO BE COMPLETED BY THE REPORTING CARRIER, IF AN AGENT IS FILING RATE FLOOR DATA ON THE CARRIER'S BEHALF:

Certification of Officer or Employee to Authorize an Agent to File Rate Floor Data on Behalf of Reporting Carrier

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

Telephone number of authorized officer or employee: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _

Study Area Code of Reporting Carrier

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

TO BE COMPLETED BY THE AUTHORIZED AGENT:

Certification of Agent Authorized to File Rate Floor Data Reported on Behalf of Reporting Carrier

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

Telephone number of authorized agent: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _

Study Area Code of Reporting Carrier

Filing Due Date for this form (mmddyyyy)