INSTRUCTIONS FOR FCC FORM 5625
Connect America Phase II New York
Long-Form Application
OMB Control No. 3060-1241
Overview
FCC Form 5625 asks for information so that the Federal Communications Commission (FCC) can determine whether applicants, selected in coordination with New York State’s New NY Broadband Program, are technically and financially capable of meeting the terms and conditions of Connect America Phase II support. For more information regarding the use of Connect America Phase II support in New York, see the FCC’s New York Auction Order (FCC 17-2).
FCC Form 5625 has two components—the Main Form and Schedule A—in addition to attachments and exhibits required by the forms. All applicants must complete the Main Form, and applicants with Disclosable Interest Holders must also complete Schedule A for each of the applicant’s Disclosable Interest Holders.
Applications must be submitted by [[6:00 p.m. EDT on ________, ______ ___, 2018]].
Main Form Instructions
Each applicant must submit one Main Form.
Applicant Information
Date Submitted. Provide the date the applicant is mailing, hand-delivering, or electronically submitting the form to the FCC.
Applicant Legal Classification. Provide the legal classification of the applicant (e.g., corporation, general partnership) by marking the appropriate circle. If the applicant is an individual, mark “Individual.”
Entity Name. Provide the legal name of the applicant.
FCC Registration Number (FRN). Provide the applicant’s FRN. If the applicant does not yet have an FRN, the applicant must register to receive one on the FCC’s website at https://apps.fcc.gov/coresWeb/.
Jurisdiction of Formation. If the applicant is an entity, provide the applicant’s jurisdiction of formation. Otherwise, write “N/A.”
Address Line 1 and 2, City, State, Zip Code, Email, and Phone. Provide the address, email, and phone number associated with the applicant.
Contact Information
13. Name. Provide the name of a point of contact for the applicant.
14. Organization. Provide the name of the contact’s organization or business.
Address Line 1 and 2, City, State, Zip Code, Email, and Phone. Provide the address, email, and phone number associated with the applicant’s point of contact.
Ownership Information
22. Disclosable Interest Holders. For each Disclosable Interest Holder of the applicant, provide the name, type of entity, FRN (if applicable), and the percent interest of the applicant held. For Disclosable Interest Holders that are individuals, write “Individual” as the type of entity. If there is insufficient space to provide a complete list of Disclosable Interest Holders, provide such a complete list in an attachment to the form.
If there are any Disclosable Interest Holders with indirect ownership of the applicant, attach a separate exhibit showing the relationship between those Disclosable Interest Holders and the applicant.
For purposes of Form 5625, a Disclosable Interest Holder is any individual or entity that has an interest in the applicant that FCC rules require be disclosed on Form 5625. Generally, these include: (1) the real party or parties in interest in the applicant or application; (2) parties holding 10% or more of stock; (3) limited partners whose interest is 10% or greater; (4) general partners; (5) members of a limited liability company whose interest is 10% or greater; and (6) parties holding indirect ownership interests in the applicant equaling 10% or greater. See 47 C.F.R. § 1.2112(a). A real party in interest is a natural person that exercises control of the applicant. There can be more than one real party in interest for an applicant. Each real party in interest must be reported as a separate Disclosable Interest Holder entry.
23. FCC-Regulated Businesses (Held by Applicant). For each FCC-Regulated Business held by the applicant, provide the name, principal business, FRN (if applicable), and the percent interest held by the applicant. If there is insufficient space to provide a complete list of FCC-Regulated Businesses held by the applicant, provide such a complete list in an attachment to the form.
For purposes of Form 5625, an FCC Regulated Business includes entities that provide services subject to regulation under any provision in the Communications Act, as amended, in which the applicant or any disclosable interest holder holds a 10% or greater interest. An applicant must include in Form 5625 a description of the FCC Regulated Business’ principal business and its relationship to the applicant, generally expressed as the percent of interest held directly by the applicant or the disclosable interest holder in the FRB. See 47 C.F.R. § 1.2112(a)(7).
Required Attachments
24. ETC Designation. Mark whether the applicant is an eligible telecommunications carrier (ETC) in areas where it is seeking Connect America Phase II support.
If the applicant has already been designated as an ETC in the areas where it is seeking Connect America Phase II support, mark “yes” and attach the relevant designation order to the application.
If the applicant has not yet been designated as an ETC in areas where it is seeking Connect America Phase II support, mark “no.” The applicant must apply for and obtain ETC designation in the relevant areas from the New York Public Service Commission, and then separately submit the relevant designation order to the FCC, along with a letter from an officer of the applicant certifying that the applicant has been designated as an ETC in the areas where it is seeking Connect America Phase II support. Submit any such documentation and accompanying certification no later than 180 days after New York announces the winning bidders, upon being designated as an ETC, by paper or electronically, in accordance with the filing information below. If the New York Public Service Commission indicates that it does not have jurisdiction over the applicant, the applicant should seek an ETC designation from the FCC in the relevant areas. See http://www.usac.org/hc/join-the-program/step01/default.aspx.
25. Construction Funding Documentation. Provide in an attachment to the form an exhibit describing how the required construction will be funded, in addition to funding from the Connect America Fund and from New York State’s New NY Broadband Program, including financial projections that demonstrate the applicant’s ability to cover the necessary debt service payments over the life of the loan, if any.
26. Network Design Documentation. Provide in an attachment to the form an exhibit describing how the technology and system design the applicant intends to use will deliver voice and broadband service, including a network diagram, (i.e., showing how the central office is connected to particular census blocks) which must be certified by a professional engineer. The professional engineer must certify that the network is capable of delivering, to at least 95 percent of the required number of locations in each relevant state, voice, and broadband service that meets the requisite performance requirements. See 47 C.F.R. § 54.309. There must be sufficient capacity to meet customer demand at or above the prescribed levels during peak usage periods. Entities proposing to use wireless technologies also must provide a description of their spectrum access in the areas for which they seek support and demonstrate that they have the required licenses to use that spectrum, if applicable.
Audited Financial Statements
26. Mark whether the applicant is providing three years of audited financial statements to New York for participation in the New NY Broadband Program. Applicants that are not providing three years of audited financial statements to New York must, in addition to submitting other information to New York, submit financial statements to the Commission from the prior fiscal year that are audited by a certified public accountant before they will be authorized to receive Connect America Phase II support no later than 180 days after New York announces the winning bidders.
Certifications
27-28. Signature and Date. After confirming the certification statements, sign and date in the spaces provided to certify the statements on behalf of the applicant. An authorized officer of the applicant may sign on behalf of the applicant.
29-30. Printed Name of Authorized Position and Title/Position of Authorized Officer. Provide the name and title/position of the authorized person signing the application.
31-33. Phone, Email, and Employer. Provide the phone number, email address, and employer of the authorized person signing the application.
Schedule A Instructions
Each applicant must submit one Schedule A for each of its Disclosable Interest Holders.
Basic Information
1. Entity or Individual Name. Provide the legal name of the Disclosable Interest Holder.
2. Disclosable Interest Holder Legal Classification. Provide the legal classification of the Disclosable Interest Holder (e.g., corporation, general partnership) by marking the appropriate circle. If the Disclosable Interest Holder is an individual, mark “Individual.”
3. FCC Registration Number (FRN). Provide the Disclosable Interest Holder’s FRN. If the Disclosable Interest Holder does not yet have an FRN, the Disclosable Interest Holder must register to receive one on the FCC’s website at https://apps.fcc.gov/coresWeb/.
4. Jurisdiction of Formation/Country of Citizenship. If the Disclosable Interest Holder is an entity, provide its jurisdiction of formation. If the Disclosable Interest Holder is an individual, provide its country of citizenship.
Address Line 1 and 2, City, State, and Zip Code. Provide the address, email, and phone number associated with the Disclosable Interest Holder.
Type of Interest in Applicant
10. Indicate the Disclosable Interest Holder’s type(s) of interest in the applicant by checking all applicable boxes.
Type of Ownership Interest in Applicant
11. If the Disclosable Interest Holder has an ownership interest in the applicant, indicate the type(s) of ownership interest by checking all applicable boxes. Specify whether the type of ownership interest is voting or non-voting, managing or non-managing, insulated or non-insulated, or convertible or non-convertible, as applicable.
FCC Regulated Businesses
12. FCC-Regulated Businesses (Held by Disclosable Interest Holder). For each FCC-Regulated Business held by the Disclosable Interest Holder, provide the name, principal business, FRN (if applicable), and the percent interest held by the Disclosable Interest Holder. If there is insufficient space to provide a complete list of FCC-Regulated Businesses held by the Disclosable Interest Holder, provide such a complete list in an attachment to the form. See 47 C.F.R. § 1.2112(a)(7).
Filing Information
Applications may be submitted by paper or electronically.
Paper Filing. Applicants who choose to file by paper must file an original and one copy of each filing. Filings can be sent by hand or messenger delivery, by commercial overnight courier, or by first-class or overnight U.S. Postal Service mail. All filings must be addressed to the Telecommunications Access Policy Division, Wireline Competition Bureau, Federal Communications Commission.
All hand-delivered or messenger-delivered paper filings must be delivered to FCC Headquarters at 445 12th St., SW, Room TW-A325, Washington, DC 20554. The filing hours are 8:00 a.m. to 7:00 p.m. All hand deliveries must be held together with rubber bands or fasteners. Any envelopes and boxes must be disposed of before entering the building.
Commercial overnight mail (other than U.S. Postal Service Express Mail and Priority Mail) must be sent to 9050 Junction Drive, Annapolis Junction, MD 20701.
U.S. Postal Service first-class, Express, and Priority mail must be addressed to 445 12th Street, SW, Washington, DC 20554.
Electronic Filing. Electronic applications must be sent to ConnectAmerica@fcc.gov.
Further Questions
For additional information about FCC Form 5625, contact the Wireline Competition Bureau, Telecommunications Access Policy Division, at ConnectAmerica@fcc.gov or (202) 418-7400.
FCC Notice for Individuals Required by the Privacy Act and the Paperwork Reduction Act
Part 3 of the Commission’s Rules authorize the FCC to request the information on this form. The purpose of the information is to determine whether applicants can meet the terms and conditions of Connect America Phase II support. The information will be used by the Universal Service Administrative Company and/or the staff of the Federal Communications Commission, to evaluate this form, to provide information for enforcement and rulemaking proceedings and to maintain a current inventory of applicants. No authorization can be granted unless all information requested is provided. Failure to provide all requested information will delay the processing of the application or result in the application being returned without action. Information requested by this form will be available for public inspection. Your response is required to obtain the requested authorization.
The public reporting for this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the required data, and completing and reviewing the collection of information. If you have any comments on this burden 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 Act Project (3060-1241), Washington, DC 20554. We will also accept your comments regarding the Paperwork Reduction Act aspects of this collection via the Internet if you send them to pra@fcc.gov. PLEASE DO NOT SEND YOUR RESPONSE 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 OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-1241.
THE FOREGOING NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. 552a(e)(3) AND THE PAPEWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.
Instructions for FCC Form 5625
February 2018
Page
| File Type | application/msword |
| Author | Stephen Wang |
| Last Modified By | SYSTEM |
| File Modified | 2018-04-09 |
| File Created | 2018-04-09 |