Business or other for-profit

OMB Control No. 3060-0986 (High-Cost)
OMB Control No. 3060-0819 (Low-Income)

[Month] 2020

Overview of FCC Form 481

Annual Reporting for High-Cost and Low-Income Universal Service Support Recipients via Online System

(Note: This is a representative description of the information to be collected via the online system for the FCC Form 481 and is not intended to be a visual representation of what filers will see.)

Line Number	Field Description	Purpose/Instructions
010	Study Area Code (SAC)	Study Area codes applicable to data filed.
015	Study Area Name	The standard name used to identify your study area. Typically the name is the same as your company name.
020	Program Year	The upcoming calendar year.
030	Contact Name	Name of the individual that prepared the data submission for your company.
035	Contact Phone Number	Telephone number of the individual that prepared the data submission for your company.
039	Contact Email Address	The email address of the individual that prepared the data submission for your company.
210	Voice Telephony Service Outage Reporting	Respond with ‘yes’ or ‘no’ if there were any reportable voice service outages in the prior calendar year.
220 (column a)	NORS Reference Number	Reference number associated with the data, for this outage incident, that was reported on the Network Outage Reporting System.
220 (column b1)	Outage Start Date	Date of the onset of the service outage. (format mm/dd/yyyy)
220 (column b2)	Outage Start Time	Time of the onset of the service outage. (format: hh/mm)
220 (column b3)	Outage End Date	Date of the end of the service outage.
220 (column b4)	Outage End Time	Time of the end of the service outage.
220 (column c1)	Number of Customers Affected	Total number of customers affected at any time during the service outage
220 (column c2)	Total Number of Customers	Amount of the study area’s total customer base.
220 (column d)	911 Facilities Affected (yes/no)	Confirm whether the outage impacted the 911 facilities’ functionality at any time during the service outage.
220 (column e)	Service Outage Description	Provide which services were affected by the service outage.
220 (column f)	Did this Service Outage Affect Multiple Study Areas	Answer yes or no if this service outage affected multiple study areas.
220 (column g)	Service Outage Resolution	Brief description of the processes used to resolve the service outage.
220 (column h)	Preventative Procedures	Brief description of the preventative procedures implemented by the carrier to avoid the occurrence of a similar service outage in the future.
400	Number of Complaints per 1,000 Customers (Voice Telephony Service)	Indicate the type(s) of voice services offered in the service area for any facilities you own, operate, lease, or otherwise utilize.
410	Complaints per 1000 customers for fixed voice	Number of Complaints per 1,000 customers for voice (fixed).
420	Complaints per 1000 customers for mobile voice	Number of Complaints per 1,000 customers for voice (mobile).
515	Certify compliance with applicable minimum service standards	Indicate yes or no to certify for compliance with applicable minimum service standards.
600	Certify compliance regarding ability to function in emergency situations	Answer yes or no to indicate that the carrier is able function in emergency situations.
610	Descriptive document for Functionality in Emergency Situations	Attach a PDF that provides details of the carrier’s preparedness to ensure continued service during an emergency situation.
810	Reporting Carrier	Name associated with the study area reported in this document
811 (a-d)	Holding Company	Name of the corporate holding company associated with the study area reported in this document.
812	Operating Company	Name of the corporate operating company designation associated with the study area reported in this document.
813 (column a1)	Affiliates	Name of any corporate affiliates associated with the study area reported In this document.
813 (column a2)	SAC	SAC associated with the affiliate ETCs.
813 (column a3)	Doing Business As Company or Brand Designation	The alternate corporate branding or legal “Doing Business As” designations associated with the study area reported in this document.
900	Does the filing entity offer tribal land services? (Y/N)	Answer Yes or No to indicate if the carrier has Tribal Land offerings.
910	Tribal Land(s) on which ETC Serves	Name of Tribal Land(s) on which the carrier provides service.
920	Tribal Government Engagement Obligation	PDF that outlines discussions the carrier has had with the Tribal governments.
921	Needs assessment and deployment planning with a focus on Tribal Community anchor institutions.	Answer yes, no, or not applicable n/a to explain as to attached document, on line 920, contains an explanation of your company’s actions to address needs assessment and deployment planning with a focus on Tribal community anchor institutions for the Tribal land network.
922	Feasibility and sustainability planning;	Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to address feasibility and sustainability planning for the Tribal land network.
923	Marketing services in a culturally sensitive manner	Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to address the marketing of services in a culturally sensitive manner in the Tribal land.
924	Compliance with Rights of way processes	Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to comply with the right-of-way processes for the Tribal lands.
925	Compliance with Land Use permitting requirements	Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to comply with the land use permitting requirements for the Tribal lands.
926	Compliance with Facilities Siting rules	Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to comply with the facilities siting rules for the Tribal lands.
927	Compliance with Environmental Review processes	Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to comply with the environmental review processes for the Tribal lands.
928	Compliance with Cultural Preservation review processes	Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to comply with the cultural preservation review processes for the Tribal lands.
929	Compliance with Tribal Business and Licensing requirements.	Answer yes, no, or not applicable to explain as to whether the attached document, on line 920, contains an explanation of your company’s actions to comply with the Tribal business and licensing requirements for the Tribal lands.
1000	Voice services rate comparability certification	Answer yes, no, or not applicable to certify that your pricing of fixed voice services is no more than two standard deviations above the applicable national average urban rate for voice service.
1010	Attach detailed description for voice services rate comparability compliance	Provide a description of how your pricing of fixed voice services is no more than two standard deviations above the applicable national average urban rate for voice service, as published annually by the Wireline Competition Bureau.
1020	Broadband comparability certification	Answer yes, no, or not applicable to certify that the pricing of a service that meets the Commission’s broadband public interest obligations is no more than the applicable benchmark to be announced annually in a public notice issued by the Wireline Competition Bureau or is no more than the non-promotional price charged for a comparable fixed wireline service in urban areas in the states or U.S. Territories where the eligible telecommunications carrier receives support.
1030	Attach detailed description for broadband comparability compliance	Provide a detailed description of how your pricing of broadband services satisfies broadband service rate comparability requirements.
1100	Certify whether terrestrial backhaul options exist (Y/N)	Confirm (yes / no) whether terrestrial backhaul options exist (yes) or whether you’re compelled to rely exclusively on satellite backhaul in your study area (no).
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).	Respond (either yes, no, or not applicable) to denote whether your company offers broadband service of at least 1 Mbps downstream and 256 kbps upstream within the supported area pursuant to § 54.313(g). This question is not applicable to companies receiving Alaska Plan support.
1140	Alaska Plan rate-of-return certification (yes, no, or not applicable) of Compliance with approved performance plan.	Answer yes, no, or not applicable to denote whether in the portion(s) of your study area that relies exclusively on satellite backhaul, your company is providing service consistent with its approved performance plan.
1210	Terms & Conditions of Voice Telephony Lifeline Plans	Attach a document which details the terms and conditions of any voice telephony service plans.
1220	Link to Public Website	Provide public website that details the terms and conditions of any voice telephony service plans.
1221	Information describing the terms and conditions of any voice telephony service plans offered to Lifeline subscribers,	Confirm that the attached document, on line 1210, or the website address, on line 1220, contains an explanation of 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,	Confirm that the attached document, on line 1210, or the website address, on line 1220, contains an explanation of the number of minutes provided as part of all plans offered in Lifeline subscribers.
1223	Additional charges for toll calls, and rates for each such plan.	Confirm that the attached document, on line 1210, or the website address, on line 1220, contains an explanation of the additional charges, if any, for toll calls, and rates as part of all plans offered to Lifeline subscribers.
2015	2016 and future Frozen Support Certification 47 CFR § 54.313(c)(4)	Answer yes or no as to whether you are compliant with 54.313(c) (4). If you do not receive Frozen support, select ‘Not Applicable’ from the drop-down menu.
2016	Certification support used to build broadband	Answer yes or no as to whether you are compliant with 54.313(d). If you do not receive ICC support, Select Not Applicable from the drop-down menu.
2017 (a)	Connect America Fund Phase II recipient?	Answer yes or no if you are a CAF Phase II Recipient.
2017 (c)	Total amount of Phase II support, if any, the price cap carrier used for capital expenditures in 2017.	Enter the total amount of Phase II Support, if any, the carrier used for capital expenditures.
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)	Upload a list containing 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.
2019	Connect America Phase II - FCC Form 470 Postings:	For the filing due July 1 following full implementation of this requirement, answer yes, no, or not applicable to this certification request.
3007	Does this filing retain a Cost Consultant and/or Cost Consultant Firm or Third Party to prepare financial and operations data disclosures submitted to the National Exchange Carrier Association (NECA), the Administrator, or the Commission?	Answer yes or no if there was a cost consultant and/or consultant firm, or other third party, involved in preparing the disclosures or any financial data in the prior year.
3007a	Name(s) of Consultant/Third Party	Enter the name(s) of any cost consultant or third party that helped in preparing the disclosures or any financial data.
3007b	Name(s) of Consultant Firm	Enter the name(s) of the cost consultant firm associated with the cost consultant named in line 3007a.
3009	Progress Report	Answer yes, no, or not applicable to this certification request. Rate-of-return carrier recipients of high-cost support must respond affirmatively that it bid on category one telecommunications and Internet access services in response to all reasonable requests in posted FCC Form 470s seeking broadband service that meets the connectivity targets for the schools and libraries universal service support program for eligible schools and libraries within its service area, and that such bids were at rates reasonably comparable to rates charged to eligible schools and libraries in urban areas for comparable offerings.
3010a	Certification of Public Interest Obligations	Answer yes - attach certification, no – attach explanation, or not applicable – no attachment required, to indicate whether this certification may be provided.
3010b	Please Provide Attachment	Attach a document either providing the certification stated (if yes) or an explanation of non-compliance (if no).
3012a	Rate-of-Return Community Anchor Institutions	Indicate if the carrier newly deployed broadband service to community anchor institution(s) in the previous calendar year.
3012b	Please Provide Attachment	Using link, download template and list the number, name and address for each community anchor institution. Attach the document which contains the community anchor institution details as required by 47 C.F.R. § 54.313(f)(1)(ii).
3013	Is your company a Privately Held ROR Carrier	Indicate whether your carrier is a privately held Rate of Return carrier as defined in 47 CFR 54.313(f)(2)
3014	If yes, does your company file the RUS annual report	Indicate whether your carrier files the RUS annual report.
3015	Electronic copy of their annual RUS reports (Operating Report for Telecommunications Borrowers)	Check the box to confirm that a copy of the RUS annual report is provided as part of the document uploaded to Line 3017.
3016	Document(s) with Balance Sheet, Income Statement and Statement of Cash Flows	Check the box to confirm that the carrier’s balance sheet, income statement and statement of cash flows are provided as part of the document uploaded to Line 3017.
3017	If the response is yes on line 3014, attach your company's RUS annual report and all required documentation	Attach a copy of the annual RUS report.
3018	If the response is no on line 3014, is your company audited?	Indicate whether you carrier’s financial statements are audited.
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	Check the box to confirm that the carrier’s audited financial statement or a financial report in a format comparable to RUS Operating Report for Telecommunications Borrowers are provided as part of the document uploaded to Line 3026.
3020	Document(s) for Balance Sheet, Income Statement and Statement of Cash Flows	Check this box to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains a 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.	Check this box to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains a copy of a management letter and/or audit opinion issued by the independent certified public accountant that performed the company’s financial audit.
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	Check this box to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains a copy of your 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	Check this box to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains the underlying information subjected to a review by an independent certified public accountant.
3024	Underlying information subjected to an officer certification.	Check this box to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains the underlying information subjected to an officer certification
3025	Document(s) with Balance Sheet, Income Statement and Statement of Cash Flows.	Check this box to confirm your submission, on line 3026 pursuant to § 54.313(f)(2), contains a Balance Sheet, Income Statement and Statement of Cash Flows.
3026	Attach the worksheet listing required information	Attach a worksheet which is compliant with the requirements if your company is a privately held RoR carrier that is not receiving loans from the RUS.
3027	Revenue	Enter the revenue amount included in the RUS report attached on line 3017 or the revenue amount included in the audited/reviewed financial statements attached on line 3026.
3028	Operating Expenses	Enter the operating expense amount included in the RUS report attached on line 3017 or the operating expense amount included in the audited/reviewed financial statements attached on line 3026.
3029	Net Income	Enter the net income amount included in the RUS report attached on line 3017 or the net income amount included in the audited/reviewed financial statements attached on line 3026.
3030	Telephone Plant in Service (TPIS)	Enter the TPIS amount included in the RUS report attached on line 3017 or the TPIS amount included in the audited/reviewed financial statements attached on line 3026.
3031	Total Assets	Enter the total assets amount included in the RUS report attached on line 3017 or the total assets amount included in the audited/reviewed financial statements attached on line 3026.
3032	Total Debt	Enter the total debt amount included in the RUS report attached on line 3017 or the total debt amount included in the audited/reviewed financial statements attached on line 3026.
3033	Total Equity	Enter the total equity amount included in the RUS report attached on line 3017 or the total equity amount included in the audited/reviewed financial statements attached on line 3026.
3034	Dividends	Enter the dividends amount included in the RUS report attached on line 3017 or the dividends amount included in the audited/reviewed financial statements attached on line 3026.
4001	Public Interest Obligations	Answer yes or no if any recipient of the RBE support offered broadband meeting the requisite public interest obligations consistent with the category for which they selected, including broadband speed, latency, usage capacity, and rates for comparable offerings in urban areas.
4003a	RBE Community Anchor Institutions	Indicate if the carrier newly deployed broadband service to community anchor institution(s) in the previous calendar year.
4003b	Please Provide Attachment	Using link, download template and list the number, name and address for each community anchor institution. Attach the document which contains the community anchor institution details as required by FCC 14-98 (paragraph 79).
5010	Do you participate in the Alaska plan?	Answer yes or no if the reporting carrier participates in the Alaska Plan.
5011	Newly Available Terrestrial or other Satellite Backhaul (RoR Carriers):	Answer yes or no whether any terrestrial backhaul or other satellite backhaul became commercially available in the previous calendar year in the areas previously served exclusively by performance-limiting satellite backhaul.
5012	Newly Available Terrestrial or other Satellite Backhaul (CETC Carriers):	Answer yes or no if any terrestrial backhaul or other satellite backhaul became commercially available in the previous calendar year in the areas that were previously served exclusively by satellite backhaul.
5013 (column a)	Description of Backhaul Technology:	Provide description of the backhaul technology.
5013 (column b)	Date Backhaul Available:	Provide date at which that backhaul was made commercially available to the carrier.
5013 (column c)	Newly Served Locations or Population:	Provide the number of locations (RoR participants) or the number of population (CETC participants) that are newly served by the new terrestrial backhaul or other satellite backhaul.
6010	Total amount of Phase II Auction support, if any, the Phase II Auction or New York recipient carrier used for capital expenditures in the previous calendar year	Enter the total amount of Phase II Auction Support, if any, the carrier used for capital expenditures.
6011	Phase II Auction and New York Available Funds Certification	Certify (either yes or no) regarding whether the recipient has available funds for all project costs that will exceed the amount of support that will be received for the next calendar year. This certification must be provided starting the first July 1st after receiving support until the recipient’s penultimate year of support.
6012a	Phase II Auction Community Anchor Institutions	Indicate if the carrier newly deployed broadband service to community anchor institution(s) in the previous calendar year.
6012b	Please Provide Attachment	Using link, download template and list the number, name and address for each community anchor institution. Attach the document which contains the community anchor institution details as required by 47 C.F.R. § 54.313(e)(2)(i)(A).
6013	Phase II Auction FCC Form 470 Postings	For the filing due July 1 following full implementation of this requirement answer yes, no, or not applicable to this certification request.
6014	Phase II Auction Post-Final Deployment Milestone Performance Certification	Starting the first July 1st after meeting the final service milestone, certify (yes or no) that the Phase II-funded network that the Phase II auction recipient operated in the prior year meets the relevant performance requirements in § 54.309.
7010	Price Cap Carrier and Fixed Competitive Eligible Telecommunications Carrier Transitional support requirement certification	Starting July 1, 2020 and for each subsequent year they receive such support, answer yes or no, that all such support the company received in the previous year was used to provide voice service throughout the high-cost and extremely high-cost census blocks where they continue to have the federal high-cost eligible telecommunications carrier obligation to provide voice service pursuant to §54.201(d) at rates that are reasonably comparable to comparable offerings in urban areas.
8010	Uniendo a Puerto Rico Stage 2 Fixed – Capital Expenditures	Enter the total amount of Uniendo a Puerto Rico Stage 2 fixed support, if any, the carrier used for capital expenditures.
8011	Uniendo a Puerto Rico Stage 2 Fixed – Available Funds Certification	Certify (either yes or no) regarding whether the recipient has available funds for all project costs that will exceed the amount of support that will be received for the next calendar year. This certification must be provided starting the first July 1st after receiving support until the recipient’s penultimate year of support.
8012a	Uniendo a Puerto Rico Stage 2 Fixed – Community Anchor Institutions	Indicate if the carrier newly deployed broadband service to community anchor institution(s) in the previous calendar year.
8012b	Please Provide Attachment	Using link, download template and list the number, name and address for each community anchor institution. Attach the document which contains the community anchor institution details as required by 47 C.F.R. § 54.313(e)(2)(i)(A).
8013	Uniendo a Puerto Rico Stage 2 Fixed – FCC Form 470 Postings	For the filing due July 1 following full implementation of this requirement answer yes, no, or not applicable to this certification request.
8014	Uniendo a Puerto Rico Stage 2 Fixed – Post-Final Deployment Milestone Performance Certification	Starting the first July 1st after meeting the final service milestone, certify (yes or no) that the Uniendo a Puerto Rico Stage 2-funded network that the Stage 2 recipient operated in the prior year meets the relevant performance requirements in § 54.309.
8020	Uniendo a Puerto Rico Stage 2 Fixed –Support Reimbursement Certification	All Stage 2 Support recipients must certify that support was not used for costs that are (or will be) reimbursed by other sources of support. Answer yes or no if reporting carrier is compliant with 54.313(n).
8030	Uniendo a Puerto Rico Stage 2 Fixed – Disaster Preparedness and Response Documentation	All Stage 2 support recipients must update their Disaster Preparation and Response Plan when they make material changes to internal processes or responsible staff and share the updated Disaster Preparation and Response Plan with the Bureau within 10 business days. Support recipients are also required to certify annually to USAC that they have recently reviewed the Disaster Preparation and Response Plan and considered whether any changes or revisions were necessary. Answer yes or no if carrier is compliant with 54.313(n) as required by 54.1515(a)-(c).
8040	Uniendo a Puerto Rico Stage 2 Mobile – Support Reimbursement Certification	All Stage 2 Support recipients must certify that support was not used for costs that are (or will be) reimbursed by other sources of support. Answer yes or no if reporting carrier is compliant with 54.313(n).
8050	Uniendo a Puerto Rico Stage 2 Mobile –Disaster Preparedness and Response Documentation	All Stage 2 support recipients must update their Disaster Preparation and Response Plan when they make material changes to internal processes or responsible staff and share the updated Disaster Preparation and Response Plan with the Bureau within 10 business days. Support recipients are also required to certify annually to USAC that they have recently reviewed the Disaster Preparation and Response Plan and considered whether any changes or revisions were necessary. Answer yes or no if carrier is compliant with 54.313(n) as required by 54.1515(a)-(c).
8060	Uniendo a Puerto Rico Stage 2 Mobile – Mobile Disbursements Certification	Recipients of Uniendo a Puerto Rico Fund Stage 2 mobile support must certify compliance with all requirements for receipt of such support to continue receiving Stage 2 mobile disbursements. Answer yes or no if carrier is compliant with 54.313(o).
9010	Connect USVI Fund Stage 2 Fixed - Capital Expenditures	Enter the total amount of Connect USVI Fund Stage 2 fixed support, if any, the carrier used for capital expenditures.
9011	Connect USVI Fund Stage 2 Fixed - Available Funds Certification	Certify (either yes or no) regarding whether the recipient has available funds for all project costs that will exceed the amount of support that will be received for the next calendar year. This certification must be provided starting the first July 1st after receiving support until the recipient’s penultimate year of support.
9012a	Connect USVI Fund Stage 2 Fixed – Community Anchor Institutions	Indicate if the carrier newly deployed broadband service to community anchor institution(s) in the previous calendar year.
9012b	Please Provide Attachment	Using link, download template and list the number, name and address for each community anchor institution. Attach the document which contains the community anchor institution details as required by 47 C.F.R. § 54.313(e)(2)(i)(A).
9013	Connect USVI Fund Stage 2 Fixed - FCC Form 470 Postings	For the filing due July 1 following full implementation of this requirement answer yes, no, or not applicable to this certification request.
9014	Connect USVI Fund Stage 2 Fixed -Post-Final Deployment Milestone Performance Certification	Starting the first July 1st after meeting the final service milestone, certify (yes or no) that the Connect USVI Fund Stage 2-funded network that the Stage 2 recipient operated in the prior year meets the relevant performance requirements in § 54.309.
9020	Connect USVI Fund Stage 2 Fixed -Support Reimbursement Certification	All Stage 2 Support recipients must certify that support was not used for costs that are (or will be) reimbursed by other sources of support. Answer yes or no if reporting carrier is compliant with 54.313(n).
9030	Connect USVI Fund Stage 2 Fixed -Disaster Preparedness and Response Documentation	All Stage 2 support recipients must update their Disaster Preparation and Response Plan when they make material changes to internal processes or responsible staff and share the updated Disaster Preparation and Response Plan with the Bureau within 10 business days. Support recipients are also required to certify annually to USAC that they have recently reviewed the Disaster Preparation and Response Plan and considered whether any changes or revisions were necessary. Answer yes or no if carrier is compliant with 54.313(n) as required by 54.1515(a)-(c).
9040	Connect USVI Fund Stage 2 Mobile - Support Reimbursement Certification	All Stage 2 Support recipients must certify that support was not used for costs that are (or will be) reimbursed by other sources of support. Answer yes or no if reporting carrier is compliant with 54.313(n).
9050	Connect USVI Fund Stage 2 Mobile - Disaster Preparedness and Response Documentation	All Stage 2 support recipients must update their Disaster Preparation and Response Plan when they make material changes to internal processes or responsible staff and share the updated Disaster Preparation and Response Plan with the Bureau within 10 business days. Support recipients are also required to certify annually to USAC that they have recently reviewed the Disaster Preparation and Response Plan and considered whether any changes or revisions were necessary. Answer yes or no if carrier is compliant with 54.313(n) as required by 54.1515(a)-(c).
9060	Connect USVI Fund Stage 2 Mobile - Mobile Disbursements Certification	Recipients of Connect USVI Fund Stage 2 mobile support must certify compliance with all requirements for receipt of such support to continue receiving Stage 2 mobile disbursements. Answer yes or no if carrier is compliant with 54.313(o).
	Certification to be completed by a reporting carrier, if the carrier is filing annual reporting on its own behalf.
	Name of Reporting Carrier	Provide the reporting carrier identification of the Study Area contained in this Form 481 filing.
	Signature of the Authorized Officer	Provide the signature of the reporting carrier’s appropriate officer attesting to this Form 481 filing.
	Date	Provide the date the reporting carrier’s appropriate officer executed this certification for this Form 481 filing.
	Printed name of Authorized Officer	Provide the name of the reporting carrier’s appropriate officer who executed this certification for this Form 481 filing.
	Title or position of the Authorized Officer	Provide title of the reporting carrier’s appropriate officer who executed this certification for this Form 481 filing.
	Telephone number of Authorized Officer	Provide the telephone number of the reporting carrier’s appropriate officer who executed this certification for this Form 481 filing.
	Study Area Code of Reporting Carrier	Provide the SAC identification code of the Study Area contained in this Form 481 filing.
	Certification of an officer to authorize an agent to file annual reports on behalf of the reporting carrier
	Name of Authorized Agent	Provide the name of the designated agent who will be executing the compliance filing on the reporting carrier’s behalf.
	Name of Reporting Carrier	Provide the reporting carrier identification of the Study Area contained in this Form 481 filing.
	Signature of Authorized Officer	Provide the signature of the reporting carrier’s appropriate officer attesting to this Form 481 filing.
	Date	Provide the date the reporting carrier’s appropriate officer executed this certification for this Form 481 filing.
	Printed Name of Authorized Officer	Provide the name of the reporting carrier’s appropriate officer who executed this certification for this Form 481 filing.
	Title or position of Authorized Officer	Provide the title of the reporting carrier’s appropriate officer who executed this certification for this Form 481 filing.
	Telephone number of Authorized Officer	Provide the telephone number of the reporting carrier’s appropriate officer who executed this certification for this Form 481 filing.
	Study Area Code of Reporting Carrier	Provide the SAC identification code of the Study Area contained in this Form 481 filing.
	Certification of agent authorized to file annual reports on behalf of the reporting carrier
	Name of Reporting Carrier	Provide the reporting carrier identification of the Study Area contained in this Form 481 filing.
	Name of the Authorized Agent Firm	Provide the name of the authorized agent firm who completed the compliance filing on the reporting carrier’s behalf.
	Signature of Authorized Agent or Employee of Agent:	Provide the signature of designated agent, or their employee, who completed this Form 481 filing on the reporting carrier’s behalf.
	Date	Provide the date the designated agent, or their employee executed this certification for this Form 481 filing.
	Name of Authorized Agent Employee	Provide the name of the agent firm’s employee who executed this certification for this Form 481 filing.
	Title or position of Authorized Agent or Employee of Agent	Provide the title of the reporting carrier’s designated agent, or its employee who executed this certification for this Form 481 filing.
	Telephone number of Authorized Agent or Employee of Agent	Provide the telephone number of the reporting carrier’s designated agent, or its employee who executed this certification for this Form 481 filing.
	Study Area Code of Reporting Carrier:	Provide the SAC identification code of the Study Area contained in this Form 481 filing (same as line 010).
	Filing Due Date for This Form	Provide the date of when the current filing of this form is due.
	Certify Filing Screen
	Supply Chain Certification	Answer yes or no if the reporting carrier is compliant with § 54.9(a). If no, carrier must provide a PDF copy of the waiver of § 54.9 granted by the FCC, or a PDF copy of the pending waiver request submitted to the FCC.

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