Legacy High-Cost Support Recipient Initial Report of Current Service Offerings

1

(Popup window that displays when “Paperwork Reduction Act Notice” hyperlink in footer is clicked)

2

3

4

5

6

(Displayed if the response to the question is “Yes”)

7

(Displayed if the response to the question is “No”)

8

9

10

11

(Displayed only if form has been drafted by someone other than the certifying official
and used to transmit the draft form to the certifying official for review and certification)

12

(Displayed only if form has been drafted by someone other than the certifying official
to confirm the draft form has been transmitted to the certifying official for review and certification)

13