FCC 481 Carrier Annual Reporting Data Collection Form

Page 1

<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 2

<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> <a> <b1> <b2> <b3> <b4> <c1> <c2> <d> <e> <f> <g> <h>

Page 3

<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

<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>

<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>

<440>

<450>

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.

Complaints per 1000 customers for fixed broadband Complaints per 1000 customers for mobile broadband

Page 5

<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>

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

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

<515> Certify compliance with applicable minimum service standards

Page 6

<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>

<600> Certify compliance regarding ability to function in emergency situations

<610> Descriptive document for Functionality in Emergency Situations

Page 7

<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

<a1>	<a2>	<a3>	<b1>	<b2>	<b3>	<b4>	<b5>	<c>
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

<703>

e e

e

Page 8

<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>

Page 9

<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

<a1> <a2> <a3>

<a1> <a2> <a3>

<a1> <a2> <a3>

<812> Operating Company

Page 10

<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> 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

Select Yes or No or

Not Applicable

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 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> 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

<927> Compliance with Environmental Review processes

<928> Compliance with Cultural Preservation review processes

<929> Compliance with Tribal Business and Licensing requirements.

Page 11

<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>

<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

<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>

<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).

Page 13

<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>

<1210> Terms & Conditions of Voice Telephony Lifeline Plans

^<1220> Link to Public Website _HTTP

Name of Attached Document

“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>

<1222>

Information describing the terms and conditions of any voice telephony service plans offered to Lifeline subscribers,

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

<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>

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

<2011> ^{3rd Year Certification 47 CFR § 54.313(b)(1)(ii) - Note that for the July 2017 certification, this applies to Round 2 recipients of Incremental Support}

<2022> ^{Recipient certifies, representing year three 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.

<2023> ^{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 three - 54.313(b)(2)(ii). Round 2 recipients only.

<2024A> ^{Round 2 Recipient of Incremental Support?}

<2024B> ^{Attach list of census blocks indicating where funding was spent in year} three - 54.313(b)(2)(ii). Round 2 recipients only.

<2025A> ^{Round 2 Recipient of Incremental Support?}

<2025B> ^{Attach geocoded Information for Phase I milestone reports (}Round 2 for year three) - Connect America Fund , WC Docket 10-90, Report and Order, FCC 13-73, paragraph 35 (May 22, 2013).

Name of Attached Document Listing Required Information

Name of Attached Document Listing Required Information

<2015> ^{2016 and future Frozen Support Certification 47 CFR § 54.313(c)(4)}

Page 15

^{Price Cap Carrier Connect America ICC Support {47 CFR §} 54.313(d)}

<2016> ^{Certification support used to build broadband}

Connect America Phase II Reporting {47 CFR § 54.313(e)}

<2017A> ^{Connect America Fund Phase II recipient?}

<2017C> Total amount of Phase II support, if any, the price cap carrier used for capital expenditures in 2016.

<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)

Name of Attached Document Listing Required Information

<2019> ^{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)(1)(ii)(C)

Page 16

<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>

Select from the drop down menu or check the boxes below to note compliance with 54.313(f)(1). Privately held carriers must ensure 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) ^{Carrier certifies to 54.313(f)(1)(iii)}

(3010A) ^{Certification of Public Interest Obligations {47 CFR § 54.313(f)(1)(i)}}

(3010B) ^{Please Provide Attachment Name of Attached Document Listing Required} Information

(3012A) ^{Community Anchor Institutions {47 CFR §} 54.313(f)(1)(ii)}

(3012B) ^{Please Provide Attachment Name of Attached Document Listing Required} Information

(3013) ^{Is your company a Privately Held ROR Carrier {47 CFR}

§ 54.313(f)(2)}

(3014) ^{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:

(3015) ^{Electronic copy of their annual RUS reports} (Operating Report for Telecommunications Borrowers)

(3016) ^{Document(s) with Balance Sheet, Income Statement} and Statement of Cash Flows

(3017) ^{If the response is yes on line 3014, attach your} company's RUS annual report and all required documentation

(3018) ^{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:

(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

(3021) ^{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:

(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

(Yes/No) (Yes/No)

Name of Attached Document Listing Required Information

(Yes/No)

(3026) ^{Attach the worksheet listing required information Name of Attached Document Listing Required}

Information

Page 17

<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>

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

(4005) Rural Broadband Experiment Additional Documentation Data Collection Form

FCC Form 481

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

Page 18

<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>

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.

Name of Attached Document Listing Required Information

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

Page 19

Certification - Reporting Carrier FCC Form 481

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>

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

Certification - Agent / Carrier _{FCC Form 481}

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>

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.

Attachments

<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>

<a> <b1> <b2> <b3> <b4> <c1> <c2> <d> <e> <f> <g> <h>

NORS Reference Number	Outage Star Date	Outage t Start 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)	Did This Outage Affect Multiple Study Areas (Yes / No)	Service Outage Resolution	Preventative Procedures

<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>

<a1>	<a2>	<a3>	<b1>	<b2>	<b3>	<b4>	<b5>	<c>
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

<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>

<a1>	<a2>	<b1>	<b2>	<c> <d1>	<d2> <d3>			<d4>
State	Exchange (ILEC)	Residential Rate	State Regulated Fees	Total Rates and Fees	Broadband Service - Download Speed (Mbps)	Broadband Service -Upload Speed (Mbps)	Usage Allowance (GB)	Usage Allowance Action Taken When Limit Reached {select}

<711>

<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