Connect America Fund - Broadband Loop Support

FCC Form 481 - Carrier Annual Reporting
Data Collection Form

Page 1

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<010> Study Area Code
<015> Study Area Name
<020> Program Year
<030> Contact Name: Person USAC should contact
with questions about this data
<035> Contact Telephone Number:
Number of the person identified in data line <030>
<039> Contact Email Address:
Email of the person identified in data line <030>

Form Type

Page 1

Page 2

(100) Service Quality Improvement Reporting
Data Collection Form

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

<110>
<111>

Has your company received its ETC certification from the FCC?
If your answer to Line <110> is yes, do you have an existing §54.202(a) "5
year plan" filed with the FCC?

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

(yes / no )
(yes / no )

If your answer to Line <111> is yes, please file a progress report, on line
<112> delineating the status of your company's existing § 54.202(a) "5 year
plan" on file with the FCC, as it relates to your provision of voice telephony
service.
<112>

Attach Five-Year Service Quality Improvement Plan or, in subsequent years,
your annual progress report filed pursuant to 47 C.F.R. § 54.313(a)(1). If your company is a
CETC which only receives frozen support, your progress report is only
required to address voice telephony service.
Name of Attached Document
Please select the appropriate responses below (Yes, No, Not Applicable) to confirm
that the attached document(s), on line 112, contains a progress report on its five-year
service quality improvement plan pursuant to §54.202(a). The information shall be
submitted at the wire center level or census block as appropriate.

<113>

Maps detailing progress towards meeting plan targets

<114>

Report how much universal service (USF) support was received

<115>

How much (USF) was used to improve service quality and how support was used to improve service quality

<116>

How much (USF) was used to improve service coverage and how support was used to improve service coverage

<117>

How much (USF) was used to improve service capacity and how support was used to improve service capacity
Provide an explanation of network improvement targets not met
in the prior calendar year.

<118>

Page 2

Page 3

(200) Service Outage Reporting (Voice)
Data Collection Form

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

<210> For the prior calendar year, were there any reportable voice service outages?
<220>

NORS
Reference
Number

Outage Start Outage Start
Date
Time

Outage End
Date

Outage End
Number of
Time
Customers Affected

Total Number of
Customers

911 Facilities
Affected
(Yes / No)

Service Outage
Description (Check
all that apply)

Did This Outage
Affect Multiple
Study Areas
(Yes / No)

Service Outage
Resolution

Preventative
Procedures

Page 3

Page 4

(300) Unfulfilled Service Request
Data Collection Form

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

<300> Unfulfilled service request (voice)
<310> Detail on attempts (voice)
Name of Attached Document

<320> Unfulfilled service request (broadband)

<330> Detail on attempts (broadband)
Name of Attached Document

Page 4

Page 5

(400) Number of Complaints per 1,000 customers
Data Collection Form

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>
<039>

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

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

<400>

Select from the drop-down list to indicate how you would like to report
voice complaints (zero or greater) for voice telephony service in the prior
calendar year for each service area in which you are designated an ETC for
any facilities you own, operate, lease, or otherwise utilize.

<410>

Complaints per 1000 customers for fixed voice

<420>

Complaints per 1000 customers for mobile voice

<430>

Select from the drop-down list to indicate how you would like to report
end-user customer complaints (zero or greater) for broadband service in
the prior calendar year for each service area in which you are designated
an ETC for any facilities you own, operate, lease, or otherwise utilize.

<440>

Complaints per 1000 customers for fixed broadband

<450>

Complaints per 1000 customers for mobile broadband

Page 5

Page 6

(500) Compliance With Service Quality Standards and Consumer Protection Rules
Data Collection Form

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<500> Certify compliance with applicable service quality standards and consumer protection rules

<510> Descriptive document for Service Quality Standards & Consumer Protection Rules Compliance

Page 6

Page 7

(600) Functionality in Emergency Situations
Data Collection Form

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<600> Certify compliance regarding ability to function in emergency situations
<610> Descriptive document for Functionality in Emergency Situations

Page 7

Page 8

(700) Price Offerings including Voice Rate Data
Data Collection Form

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

<701>

Residential Local Service Charge Effective Date

<702>

Single State-wide Residential Local Service Charge

<703>

State

Exchange (ILEC)

SAC (CETC)

Rate Type

Residential Local
Service Rate

State Subscriber Line Charge

State Universal Service Fee

Mandatory Extended Area
Service Charge

Total per line Rates and Fees

Page 8

Page 9

FCC Form 481

(710) Broadbrand Price Offerings
Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

<711>

State

Exchange (ILEC)

Residential Rate

State Regulated
Fees

Total Rate and Fees

Broadband Service Broadband Service Download Speed
(Mbps)
Upload Speed (Mbps)

Usage Allowance
(GB)

Usage Allowance
Action Taken When
Limit Reached {select }

Page 9

Page 10

(800) Operating Companies

FCC Form 481
OMB Control No. 3060-0986 /OMB Control No. 3060-0819
July 2013

Data Collection Form

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

<810>

Reporting Carrier

<811>

Holding Company

<812>

Operating Company

<813>

Affiliates

SAC

Doing Business As Company or Brand Designation

Page 10

Page 11

(900) Tribal Lands Reporting
Data Collection Form

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

<900>

FCC Form 481
OMB Control No. 3060-0986 /OMB Control No. 3060-0819
July 2013

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

<910>

Tribal Land(s) on which ETC Serves

<920>

Tribal Government Engagement Obligation
Name of Attached Document

If your company serves Tribal lands, please select (Yes,No, NA) for each these boxes
to confirm the status described on the attached document(s), on line 920,
demonstrates coordination with the Tribal government pursuant to
§ 54.313(a)(9) includes:

<921>

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

<922>
<923>
<924>
<925>
<926>
<927>
<928>
<929>

Feasibility and sustainability planning;
Marketing services in a culturally sensitive manner;
Compliance with Rights of way processes
Compliance with Land Use permitting requirements
Compliance with Facilities Siting rules
Compliance with Environmental Review processes
Compliance with Cultural Preservation review processes
Compliance with Tribal Business and Licensing requirements.

Select
Yes or No or
Not Applicable

Page 11

Page 12

(1000) Voice and Broadband Service Rate Comparability
Data Collection Form

<010>
<015>
<020>
<030>
<035>
<039>

FCC Form 481
OMB Control No. 3060-0986 /OMB Control No. 3060-0819
July 2013

Study Area Code
Study Area Name
Program Year
Contact Name - Person USAC should contact regarding this data
Contact Telephone Number - Number of person identified in data line <030>
Contact Email Address - Email Address of person identified in data line <030>

<1000>

Voice services rate comparability certification

<1010>

Attach detailed description for voice services rate
comparability compliance
Name of Attached Document

<1020>

Broadband comparability certification

<1030>

Attach detailed description for broadband
comparability compliance
Name of Attached Document

Page 12

Page 13

(1100) No Terrestrial Backhaul Reporting
Data Collection Form

<010>
<015>
<020>
<030>
<035>
<039>

<1100>

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

Study Area Code
Study Area Name
Program Year
Contact Name - Person USAC should contact regarding this data
Contact Telephone Number - Number of person identified in data line <030>
Contact Email Address - Email Address of person identified in data line <030>

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).

Page 13

Page 14

(1200) Terms and Condition for Lifeline Customers
Lifeline
Data Collection Form
<010>
<015>
<020>
<030>
<035>
<039>

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

Study Area Code
Study Area Name
Program Year
Contact Name - Person USAC should contact regarding this data
Contact Telephone Number - Number of person identified in data line <030>
Contact Email Address - Email Address of person identified in data line <030>

<1210> Terms & Conditions of Voice Telephony Lifeline Plans
Name of Attached Document

<1220>

Link to Public Website

HTTP

“Please check these boxes below to confirm that the attached document(s), on line 1210,
or the website listed, on line 1220, contains the required information pursuant to
§ 54.422(a)(2) annual reporting for ETCs receiving low-income support, carriers must
annually report:

<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.

Page 14

Page 15

(2000) Price Cap Carrier Additional Documentation
Data Collection Form
Including Rate-of-Return Carriers affiliated with Price Cap Local Exchange Carriers
<010>
<015>
<020>
<030>
<035>
<039>

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

Study Area Code
Study Area Name
Program Year
Contact Name - Person USAC should contact regarding this data
Contact Telephone Number - Number of person identified in data line <030>
Contact Email Address - Email Address of person identified in data line <030>

Select the appropriate responses below (Yes, No, Not Applicable) to note compliance as a recipient of Incremental High Cost support, High Cost support to offset access charge reductions,
and Connect America Phase II support as set forth in 47 CFR § 54.313(b),(c),(d),(e). The information reported on this form and in the documents attached below is accurate.

Incremental Connect America Phase I reporting
2nd Year Certification 47 CFR § 54.313(b)(1)(i) - Note that for the July 1
<2010>
<2011>
<2022>

<2023>

<2024A>
<2024B>

2016 certification, this applies to Round 2 recipients of Incremental
Support
3rd Year Certification 47 CFR § 54.313(b)(1)(ii) - Note that for the July 1
2016 certification, this applies to Round 1 recipients of Incremental
Support
Recipient certifies, representing year two after filing a notice of
acceptance of funding pursuant to 54.312(c), that the locations in
question are not receiving support under the Broadband Initiatives
Program or the Broadband Technology Opportunities Program for
projects that will provide broadband with speeds of at least 4
Mbps/1Mbps - 54.313(b)(2)(i). Round 2 recipients only.
The attachment on line 2024 includes a statement of the total amount of
capital funding expended in the previous year in meeting Connect
America Phase I deployment obligations, accompanied by a list of census
blocks indicating where funding was spent. This covers year two 54.313(b)(2)(ii). Round 2 recipients only.
Round 2 Recipient of Incremental Support?
Attach list of census blocks indicating where funding was spent in year
two - 54.313(b)(2)(ii). Round 2 recipients only.
Round 1 or Round 2 Recipient of Incremental Support?

Name of Attached Document Listing
Required Information

<2025B>

Attach geocoded Information for Phase I milestone reports (Round 1 for
year three and Round 2 for year two) - Connect America Fund , WC
Docket 10-90, Report and Order, FCC 13-

Name of Attached Document Listing
Required Information

<2015>

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

<2025A>

Page 15

Page 16

(2000) Price Cap Carrier Additional Documentation (Continued)
Data Collection Form
Including Rate-of-Return Carriers affiliated with Price Cap Local Exchange Carriers

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

Price Cap Carrier Connect America ICC Support {47 CFR § 54.313(d)}
Certification support used to build broadband
<2016>
Connect America Phase II Reporting {47 CFR § 54.313(e)}
<2017A> Connect America Fund Phase II recipient?

<2017B>

<2018>

<2019>

<2020>
<2021>
<2026>
<2027>

Attach information for Phase II - 54.313(e)(1) - list of geocoded locations
already meeting the 54.309 public interest obligations at the end of
calendar year 2015 and total amount of Phase II support, if any, the price

cap carrier used for capital expenditures in 2015.
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)(2)(ii)

Name of Attached Document Listing
Required Information

Name of Attached Document Listing
Required Information

Recipient certifies that it bid on category one telecommunications and
Internet access services in response to all FCC Form 470 postings seeking
broadband service that meets the connectivity targets for the schools and
libraries universal service support program for eligible schools and
libraries located within any area in a census block where the carrier is
receiving Phase II model-based support, and that such bids were at rates
reasonably comparable to rates charged to eligible schools and libraries in
urban areas for comparable offerings - 54.313(e)(2)(v)
Recipient certifies that it offered broadband meeting the requisite public
interest obligations specified in §54.309 to 40% of its supported locations
in the state on December 31, 2017 - 54.313(e)(3)
Recipient certifies that it offered broadband meeting the requisite public
interest obligations specified in §54.309 to 60% of its supported locations
in the state on December 31, 2018 - 54.313(e)(4)
Recipient certifies that it offered broadband meeting the requisite public
interest obligations specified in §54.309 to 80% of its supported locations
in the state on December 31, 2019 - 54.313(e)(5)
Recipient certifies that it offered broadband meeting the requisite public
interest obligations specified in §54.309 to 100% of its supported locations
in the state on December 31, 2020 - 54.313(e)(6)
Page 16

Page 17

(3005) Rate Of Return Carrier Additional Documentation

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

Data Collection Form

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

Complete the items below to note compliance with five year service quality plan (pursuant to 47 CFR § 54.202(a)) and, for privately held carriers, ensuring
compliance with the financial reporting requirements set forth in 47 CFR § 54.313(f)(2). I further certify that the information reported on this form and in
the documents attached below is accurate.
(3009)

Progress Report on 5 Year Plan
Carrier certifies to 54.313(f)(1)(iii)

(3010A)

Milestone Certification {47 CFR § 54.313(f)(1)(i)}

(3010B)

Please Provide Attachment

(3012A)

Community Anchor Institutions {47 CFR §
54.313(f)(1)(ii)}
Please Provide Attachment

(3012B)
(3013)
(3014)

(3015)
(3016)
(3017)
(3018)

(3019)
(3020)
(3021)

(3022)

(3023)

Is your company a Privately Held ROR Carrier {47 CFR
§ 54.313(f)(2)}
If yes, does your company file the RUS annual report
Please check these boxes to confirm that the
attached PDF, on line 3017, contains the required
information pursuant to § 54.313(f)(2) compliance
requires:
Electronic copy of their annual RUS reports
(Operating Report for Telecommunications
Borrowers)
Document(s) with Balance Sheet, Income Statement
and Statement of Cash Flows
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?
If the response is yes on line 3018, please check the
boxes below to confirm your submission on line
3026 pursuant to § 54.313(f)(2), contains:
Either a copy of their audited financial statement; or
(2) a financial report in a format comparable to RUS
Operating Report for Telecommunications Borrowers
Document(s) for Balance Sheet, Income Statement
and Statement of Cash Flows
Management letter and/or audit opinion issued by
the independent certified public accountant that
performed the company’s financial audit.
If the response is no on line 3018, please check the
boxes below to confirm your submission on line
3026 pursuant to § 54.313(f)(2), contains:
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
Underlying information subjected to a review by an
independent certified public accountant

(3024)

Underlying information subjected to an officer
certification.

(3025)

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

(3026)

Attach the worksheet listing required information

Name of Attached Document Listing Required
Information
Name of Attached Document Listing Required
Information
(Yes/No)
(Yes/No)

Name of Attached Document Listing Required
Information
(Yes/No)

Name of Attached Document Listing Required
Information

page 17

Page 18
(3005) Rate Of Return Carrier Additional Documentation (Continued)

FCC Form 481

Data Collection Form

OMB Control No. 3060-0986/OMB Control No. 3060-0819

July 2013
<010>
<015>
<020>
<030>
<035>
<039>

Study Area Code
Study Area Name
Program Year
Contact Name - Person USAC should contact regarding this data
Contact Telephone Number - Number of person identified in data line <030>
Contact Email Address - Email Address of person identified in data line <030>

Financial Data Summary

(3027) Revenue
(3028) Operating Expenses
(3029) Net Income
(3030) Telephone Plant In Service(TPIS)
(3031) Total Assets
(3032) Total Debt
(3033) Total Equity
(3034) Dividends

Name of Attached Document Listing Required Information

Page 18

Page 19

(4005) Rural Broadband Experiment Additional Documentation
Data Collection Form

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<010>
<015>
<020>
<030>
<035>
<039>

Study Area Code
Study Area Name
Program Year
Contact Name - Person USAC should contact regarding this data
Contact Telephone Number - Number of person identified in data line <030>
Contact Email Address - Email Address of person identified in data line <030>

4005 Rural Broadband Experiment
Authorized Rural Broadband Experiment (RBE) recipients must address the certification for public interest obligations, provide a list of newly served
community anchor institutions, and provide a list of locations where broadband has been deployed.
Public Interest Obligations – FCC 14-98 (paragraphs 26-29, 78)
Please address Line 4001 regarding compliance with the Commission’s public interest obligations. All RBE participants must provide a response to Line 4001.
4001. Recipient certifies that it is offering broadband to the identified locations meeting the requisite public
interest obligations consistent with the category for which they were selected, including broadband speed,
latency, usage capacity, and rates that are reasonably comparable to rates for comparable offerings in urban
areas?
Community Anchor Institutions – FCC 14-98 (paragraph 79)
4003a. RBE participants must provide the number, names, and addresses of community anchor institutions to
which they newly deployed broadband service in the preceding calendar year. On this line, please respond
(yes – attach new community anchors, no – no new anchors) to indicate whether this list will be provided.
If yes to 4003A, please provide a response for 4003B.
4003b. Provide the number, names and addresses
of community anchor institutions to which the
recipient newly began providing access to
broadband service in the preceding calendar year.

Name of Attached Document Listing Required Information

Broadband Deployment Locations – FCC 14-98 (paragraph 80)
4004a. Attach a list of geocoded locations to
which broadband has been deployed as of the
June 1st immediately preceding the July 1st filing
deadline for the FCC Form 481.
4004b. Attach evidence demonstrating that the
recipient is meeting the relevant public service
obligations for the identified locations. Materials
must at least detail the pricing, offered broadband
speed and data usage allowances available in the
relevant geographic area.

Name of Attached Document Listing Required Information

Name of Attached Document Listing Required Information

page 19

Page 20

Certification - Reporting Carrier
Data Collection Form

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

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 CAF or LI Recipients
I certify that I am an officer of the reporting carrier; my responsibilities include ensuring the accuracy of the annual reporting requirements for universal service support
recipients; and, to the best of my knowledge, the information reported on this form and in any attachments 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:
Study Area Code of Reporting Carrier:

Filing Due Date for this form:

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.

Page 20

Page 21

Certification - Agent / Carrier
Data Collection Form

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

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 CAF or LI 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:
Study Area Code of Reporting Carrier:

Filing Due Date for this form:

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.

TO BE COMPLETED BY THE AUTHORIZED AGENT:

Certification of Agent Authorized to File Annual Reports for CAF or LI Recipients on Behalf of Reporting Carrier
I, as agent for the reporting carrier, certify that I am authorized to submit the annual reports for universal service support 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 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:

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.

Page 21

Attachments

(200) Service Outage Reporting (Voice)
Data Collection Form

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

<210> For the prior calendar year, were there any reportable voice service outages?
<220>

NORS
Reference
Number

Outage
Outage Start Start
Date
Time

Outage End
Date

Outage
End
Time

Number of
Customers
Affected

Total
Number of
Customers

911
Facilities
Affected
(Yes / No)

Service Outage
Description (Check
all that apply)

Service Outage
Resolution

Preventative
Procedures

Did This Outage
Affect Multiple
Study Areas
(Yes / No)

(700) Price Offerings including Voice Rate Data
Data Collection Form

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

<701>

Residential Local Service Charge Effective Date

<702>

Single State-wide Residential Local Service Charge

<703>

State

Exchange (ILEC)

SAC (CETC)

Rate Type

Residential Local
Service Rate

State Subscriber Line Charge

State Universal Service Fee

Mandatory Extended Area
Service Charge

Total per line Rates and Fees

(710) Broadband Price Offerings
Data Collection Form

FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

<711>

State

Exchange (ILEC)

Residential
Rate

State Regulated
Fees

Total Rates
and Fees

Usage Allowance
Broadband Service - Broadband Service
Download Speed -Upload Speed (Mbps) (GB)
(Mbps)

Usage Allowance
Action Taken
When Limit Reached {select}

(800) Operating Companies

FCC Form 481
OMB Control No. 3060-0986 /OMB Control No. 3060-0819
July 2013

Data Collection Form

<010>

Study Area Code

<015>

Study Area Name

<020>

Program Year

<030>

Contact Name - Person USAC should contact regarding this data

<035>

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

<039>

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

<810>

Reporting Carrier

<811>

Holding Company

<812>

Operating Company

<813>

Affiliates

SAC

Doing Business As Company or Brand Designation