Form FCC Form 690 FCC Form 690 Phase I - Section 54.1009 Annual Reporting Data Collecti

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Overview

Form
(050) Carrier Contact Form
(060) Carrier Coverage
(070) Urban Rate Cert
(080)_Tribal Land forms
(090) Project Update
CERTIFICATION-REPORTING CARRIER
CERTIFICATION-AGENT

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Sheet 1: Form

										FCC Form 690
MOBILITY FUND										Approved by OMB
PHASE 1 - §54.1009 ANNUAL REPORTING										OMB Control No. 3060-1185
DATA COLLECTION FORM										Avg. Burden Estimate per Respondent: 18 Hours
(010)	Study Area Code							(010)
(015)	Study Area Name							(015)
(020)	Program Year							(020)	2012
(030)	Contact Name: Person USAC should contact
	with questions about this data							(040)
(035)	Contact Telephone Number:
	Number of the person identified in Data Line (030)							(045)
(039)	Contact Email:
	Email of the person identified in Data Line (030)							(049)
									(check box when complete)
(040)	Has the information required pursuant to §54.1009 been provided with a Form 481 filing (Y/N)?								(040)
		Attach a description of the documents filed with the Form 481 reporting							(041)
		Cite the Study Area Code for the Form 481 reporting							(042)
		Cite the date of the Form 481 reporting							(043)
(050)	Carrier Contact Form		(has contact info. changed since prior filing? Yes or No)
					(if yes, complete attached worksheet)				(050)
(060)	Coverage and Performance Report					(complete attached worksheet)			(060)
(070)	Urban Rate Comparability Certification					(complete attached certification)			(070)
(080)	Tribal Lands Reporting (Y/N)?
			(Does this study area cover tribal lands? Yes or No)
					(if yes, complete attached worksheet)				(080)
(090)	Project Update Information					(complete attached worksheet)			(090)
(100)	Certifications
		Reporting Carrier Certification				(complete attached certification)			(101)
		Agent Certification				(complete attached certification)			(102)
Notice to Individuals Required by the Paperwork Reduction Act of 1995
OMB Control Number 3060-1185 (Annual Report for Mobility Fund Phase I Support, FCC Form 690 and Record Retention Requirements)
Notice to Individuals Required by the Paperwork Reduction Act of 1995
Public reporting burden for this collection of information is estimated to average 18 hours per response. Our estimate includes the time to read the instructions, look through existing records, gather and maintain required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, Office of Managing Director, AMD‑PERM, Washington, DC 20554, Paperwork Reduction Act Project (3060‑1185). We will also accept your PRA comments if you send an email to PRA@fcc.gov.
Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. 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 OMB control number and/or we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060‑1185.
THIS NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

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Sheet 2: (050) Carrier Contact Form

{ 050} Carrier Contact Form
(010)	Study Area Code							(010)
(015)	Study Area Name							(015)
(020)	Program Year							(020)	2012
(030)	Contact Name: Person USAC should contact with questions about this data							(030)
(035)	Contact Telephone Number:			Number of the person identified in Data Line (030)				(035)
(039)	Contact Email:		Email of the person identified in Data Line (030)					(039)
Reporting Carrier / Mobility Fund Phase 1 Winning Bidder
(110)	FCC Registration Number
(111)	Filing Carrier Name
(112)	Winning Bidder Carrier Name
(113)	Street Address (or PO Box)
(114)	City
(115)	State
(116)	Zip-Code
(117)	Telephone Number
(118)	Fax Number
(119)	Email Address
Contact Information			if same as above, indicate in this box
(120)	Name (First, MI, Last, Suffix)
(121)	Filing Carrier Name
(122)	Street Address (or PO Box)
(123)	City
(124)	State
(125)	Zip-Code
(126)	Telephone Number
(127)	Fax Number
(128)	Email Address
				akavelman: flag to discuss with FCC. Unclear what data they want to collect
Authorized Agent Information				if no agent, indicate in this box
(130)	Name (First, MI, Last, Suffix)
(131)	Company
(132)	Street Address (or PO Box)
(133)	City
(134)	State
(135)	Zip-Code
(136)	Telephone Number
(137)	Fax Number
(138)	Email Address

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Sheet 3: (060) Carrier Coverage

(060) Coverage and Performance Report

<010>

Study Area Code

<010>

_________________

<015>

Study Area Name

<015>

_________________

<020>

Program Year

<020>

_________________

<030>

Contact Name - Person USAC should contact regarding this data

<030>

_________________

<035>

Contact Telephone Number - Number of person identified in data line <030>

<035>

_________________

<039>

Contact Email Address - Email Address of person identified in data line <030>

<039>

_________________

<140>

Coverage and Performance Report Year

<041>

_________________

<141>

<a1>

<a2>

<a3>

<b1>

<b2>

<b3>

<c1>

<c2>

<c3>

<d>

<e>

<f>

State

County

Census Block

Resident Population per Census Block

Resident Population Newly Reached by Service

Total Resident Population Reached by Service

Road Miles per Census Block

Road Miles per Census Block Newly Served

Total Road Miles Covered per Census Block

Certify Electronic Shapefiles are attached (Yes/No)

Certify: Drive Test Results are attached (Yes/No)

Certify: Scattered Site Test Results are attached (Yes/No)

Total

Total

Total

Total

Total

Total

Percentage of Population reached by service

{Column "b3" total} divided by {Column "b1" total}

Percentage of Road Miles covered by service

{Column "c3" total} divided by {Column "c1" total}

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Sheet 4: (070) Urban Rate Cert

(070) Urban Rate Comparability Certification Compliance

The Reporting Carrier offers service in supported areas at rates that are within a reasonable range of rates for similar service plans offered by mobile wireless providers in urban areas.

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

Certification of Officer as to Compliance with 47 CFR §54.1009(a)(4)

I certify that I am an officer or employee of the reporting carrier; my responsibilities include ensuring compliance with 47 CFR §54.1009(a)(4), the information reported on this form is accurate.

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: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _

Study Area Code of Reporting Carrier

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

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

Certification of Officer or Employee to Authorize an Agent to File Compliance with 47 CFR §54.1009(a)(4) on Behalf of Reporting Carrier

I certify that (Name of Agent)_______________________________________________________ is authorized to submit the information reported 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 compliance with 47 CFR §54.1009(a)(4) as reported to the authorized agent; and, to the best of my knowledge, the certification provided to the authorized agent is accurate.

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: ( _ _ _ ) _ _ _ - _ _ _ _, 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 Compliance with 47 CFR §54.1009(a)(4) on Behalf of Reporting Carrier

I, as agent for the reporting carrier, certify that I am authorized to submit the certification on behalf of the reporting carrier; I have provided the data 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 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)

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Sheet 5: (080)_Tribal Land forms

(080) Tribal Lands Reporting
<010>	Study Area Code				<010>	_________________
<015>	Study Area Name				<015>	_________________
<020>	Program Year				<020>	_________________
<030>	Contact Name - Person USAC should contact regarding this data				<030>	_________________
<035>	Contact Telephone Number - Number of person identified in data line <030>				<035>	_________________
<039>	Contact Email Address - Email Address of person identified in data line <030>				<039>	_________________
<140>	Coverage and Performance Report Year				<041>	_________________
	<142>	State
	<143>	County
	<144>	Tribal Lands on which the ETC serves
	<145>	Tribal Government Engagement Obligation	{Name of PDF}
		If your company serves Tribal lands, please select (Yes,No, NA) for each these boxes to confirm the status described on the attached PDF, on line 145, demonstrates coordination with the Tribal government pursuant to § 54.1004 includes:
			Select (Yes,No, NA)
	<146>	Needs assessment and deployment planning with a focus on Tribal community anchor institutions;
	<147>	Feasibility and sustainability planning;
	<148>	Marketing services in a culturally sensitive manner;
	<149>	Compliance with Rights of way processes
	<150>	Compliance with Land Use permitting requirements
	<151>	Compliance with Facilities Siting rules
	<152>	Compliance with Environmental Review processes
	<153>	Compliance with Cultural Preservation review processes
	<154>	Compliance with Tribal Business and Licensing requirements.

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Sheet 6: (090) Project Update

(090) Project Update Information
<010>	Study Area Code					<010>	_________________
<015>	Study Area Name					<015>	_________________
<020>	Program Year					<020>	_________________
<030>	Contact Name - Person USAC should contact regarding this data					<030>	_________________
<035>	Contact Telephone Number - Number of person identified in data line <030>					<035>	_________________
<039>	Contact Email Address - Email Address of person identified in data line <030>					<039>	_________________
<200>	Date Authorized to Receive Support
<201>	Targeted Completion Date
<202>	Total Mobility Fund Support Awarded
<203>	Total Mobility Fund Support Disbursed
<204>	Support Applied to Network Design
<205>	Support Applied to Construction
<206>	Support Applied to Deployment
<207>	Support Applied to Maintenance
<208>	Certify Network will Support 3G Mobile Service (Yes/No)
<209>	Certify Network will Support 4G Mobile Service (Yes/No)
<210>	Actual Completion Date
<211>	Project Status Description attached
<212>	Status of Network Deployment – Network Design
<213>	Status of Network Deployment – Construction
<214>	Status of Network Deployment – Deployment
<215>	Status of Network Deployment – Maintenance
<216>	Project Budget Status
<217>	Project Plan Status

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Sheet 7: CERTIFICATION-REPORTING CARRIER

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

Certification of Officer as to the Accuracy of the Data Reported for the Annual Reporting for Mobility Fund Recipients

I certify that I am an officer of the reporting carrier; my responsibilities include ensuring the accuracy of the annual reporting requirements for Mobility Fund recipients; and, to the best of my knowledge, the information reported on this form is accurate.

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: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _

Study Area Code of Reporting Carrier

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

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Sheet 8: CERTIFICATION-AGENT

TO BE COMPLETED BY THE REPORTING CARRIER, IF AN AGENT IS FILING ANNUAL REPORTS ON THE CARRIER'S BEHALF:

Certification of Officer to Authorize an Agent to File Annual Reports for Mobility Fund Recipients on Behalf of Reporting Carrier

I certify that (Name of Agent)_______________________________________________________ is authorized to submit the information reported on behalf of the reporting carrier. I also certify that I am an officer of the reporting carrier; my responsibilities include ensuring the accuracy of the annual data reporting requirements provided to the authorized agent; and, to the best of my knowledge, the reports and data provided to the authorized agent is accurate.

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: ( _ _ _ ) _ _ _ - _ _ _ _, 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 Annual Reports for Mobility Fund Recipients on Behalf of Reporting Carrier

I, as agent for the reporting carrier, certify that I am authorized to submit the annual reports for Mobility Fund recipients on behalf of the reporting carrier; I have provided the data 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 Reporting Carrier

Name of Authorized Agent or Employee of 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 or Employee of Agent: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _

Study Area Code of Reporting Carrier

Filing Due Date for this form (mmddyyyy)