CONNECT AMERICA FUND-BROADBAND LOOP SUPPORT ACTUAL COST AND REVENUE DATA COLLECTION |
Block 1 - Contact Information |
ROW # |
DATA ELEMENT |
FORMAT OF REQUESTED DATA |
RESPONSE |
1 |
Carrier Study Area Code |
6 numeric digits |
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2 |
Carrier Study Area Name |
alpha characters |
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3 |
Service Provider Identification Number |
9 numeric digits |
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4 |
Data Period (specify years) |
mm/dd/yyyy - mm/dd/yyyy |
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5 |
Date of Submission |
mm/dd/yyyy |
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6 |
Contact Name |
alpha characters |
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7 |
Contact Telephone Number [including area code] |
10 numeric digits |
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8 |
Contact E-mail Address |
alpha/numeric characters |
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Block 2 - Actual CAF-BLS by Study Area |
9 |
Annual Common Line Costs for the reporting period |
amount in $ |
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10 |
Annual Consumer Broadband-Only Loop Costs for the reporting period |
amount in $ |
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11 |
Annual SLC Revenues for the reporting period |
amount in $ |
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12a |
Average Monthly Broadband-Only Loops |
numeric digits |
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12b |
Average Monthly Broadband-Only Loops * 12 * $42 |
amount in $ |
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12c |
Lesser of Annual Consumer Broadband-Only Loop Costs or Average Monthly Broadband-Only Loops * 12 * $42 |
amount in $ |
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12d |
Blended Average of Consumer Broadband-Only rates charged during time period pursuant to Section 69.132 |
amount in $ |
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12e |
Apply Row 12d * Row 12a * 12 months |
amount in $ |
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12 |
Annual Consumer Broadband-Only Revenues for the reporting period (Provide the greater of Row 12c or Row 12e) |
amount in $ |
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13 |
Annual Special Access Surcharges for the reporting period |
amount in $ |
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14 |
Annual Line Port Costs in Excess of Basic Analog Service for the reporting period |
amount in $ |
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TO BE COMPLETED BY THE REPORTING CARRIER, IF THE REPORTING CARRIER IS FILING FCC FORM 509 ON ITS OWN BEHALF: |
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Certification of Officer or Employee as to the Accuracy of the Data Reported in FCC Form 509, Connect America Fund-Broadband Loop Support Mechanism Annual CAF-BLS Actual Cost and Revenue Data Collection Form, on Behalf of Reporting Carrier |
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Signature of authorized officer or employee |
Date |
Printed name of authorized officer or employee |
Title or position of authorized officer or employee |
Email address of authorized officer or employee |
Telephone number of authorized officer or employee: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _ |
Study Area Code of Reporting Carrier |
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Filing Due Date for this form (mm/dd/yyyy) |
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TO BE COMPLETED BY THE REPORTING CARRIER, IF AN AGENT IS FILING FCC FORM 509 ON THE CARRIER'S BEHALF: |
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Certification of Officer or Employee to Authorize an Agent to File FCC Form 509, Connect America Fund-Broadband Loop Support Mechanism Annual CAF-BLS Actual Cost and Revenue Data Collection Form, on Behalf of Reporting Carrier |
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Name of Authorized Agent |
Name of Reporting Carrier |
Signature of authorized officer or employee |
Date |
Printed name of authorized officer or employee |
Email address of authorized officer or employee |
Title or position of authorized officer or employee |
Telephone number of authorized officer or employee: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _ |
Study Area Code of Reporting Carrier |
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Filing Due Date for this form (mm/dd/yyyy) |
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TO BE COMPLETED BY THE AUTHORIZED AGENT: |
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Certification of Agent Authorized to File FCC Form 509, Connect America Fund-Broadband Loop Support Annual CAF BLS Actual Cost and Revenue Data Collection Form, on Behalf of Reporting Carrier |
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Name of Reporting Carrier |
Name of Authorized Agent |
Signature of authorized agent or employee of agent |
Date |
Printed name of authorized agent or employee of agent |
Email address of authorized agent or employee of agent |
Title or position of authorized agent or employee of agent |
Telephone number of authorized agent: ( _ _ _ ) _ _ _ - _ _ _ _, ext. _ _ _ _ _ |
Study Area Code of Reporting Carrier |
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Filing Due Date for this form (mm/dd/yyyy) |
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