Fcc Form 497 – Fill Out and Use This PDF

FCC Form 497

April 2012 EditionLIFELINE WORKSHEETOMB Approval

3060-0819

Avg. Burden Est. per Respondent: 2.5 Hrs.

(20) CERTIFICATIONS AND SIGNATURES

I certify that my company will pass through the full amount of all Non-Tribal and Tribal federal Lifeline support for which it seeks reimbursement, as well as all applicable intrastate Lifeline support, to all qualifying low-income subscribers by an equivalent reduction in the subscriber's monthly bill for voice telephony service, or by offering a pre-paid wireless plan that includes a set number of minutes of use per month.

I certify that my company is in compliance with all of the Lifeline program rules, and, to the extent required, have obtained valid certifications for each subscriber for whom my company seeks reimbursement.

Based on the information known to me or provided to me by employees responsible for the preparation of the data being submitted, I certify under penalty of perjury that the data contained in this form has been examined and reviewed and is true, accurate, and complete.

I acknowledge the Fund Administrator's authority to request additional supporting information as may be necessary.

Persons willfully making false statements on this form can be punished by fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. §1001.

DATE	OFFICER SIGNATURE
OFFICER TITLE	OFFICER NAME

NOTICE: To implement section 254 of the Communications Act of 1934, as amended, the Federal Communications Commission has adopted changes to the federal low-income programs.

The following worksheet provides the means by which eligible telecommunications carriers will be reimbursed by the Universal Service Administrative Company (USAC) for their participation in these programs. Failing to collect the information, or collecting it less frequently, would prevent the Commission from implementing sections 214 and 254 of the Act, would thwart Congress' goals of providing affordable service and access to advanced services throughout the nation, and would result in eligible telecommunications carriers not receiving universal service support reimbursements in a timely fashion.

We have estimated that each response to this collection of information will take, on average, three hours for each respondent. Our estimate includes the time to read this data request, review existing records, gather and maintain required data, and complete and review the response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Washington, D.C. 20554, Paperwork Reduction Project (3060-0819). We will also accept your comments on the burden estimate via the Internet if you send them to PRA@fcc.gov. Please DO NOT SEND the data requested to this e-mail address.

Remember -- An agency may not conduct or sponsor, and a person is not required to respond to a collection of information sponsored by the Federal government unless it displays a currently valid OMB control number. This information collection has been assigned OMB Control Number: 3060-0819.

The FCC is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. If we believe there may be a violation or a potential violation of a FCC statute, regulation, rule or order, your worksheet may be referred to the Federal, state or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation or order. In certain cases, the information in your worksheets may be disclosed to the Department of Justice or a court or adjudicative body when (a) the FCC; or (b) any employee of the FCC; or (c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding.

If you do not provide the information we request on the form, the FCC may delay processing of your worksheet or may return your worksheet without action.

The foregoing Notice is required by the Privacy Act of 1974, Pub. L. No. 93-579, December 31, 1974, 5 U.S.C. Section 552, and the Paperwork Reduction Act of 1995, Pub. L. No. 104-13, 44 U.S.C. Section 3501, et seq.

FCC Form 497

April 2012 EditionLIFELINE WORKSHEETOMB Approval

3060-0819

Avg. Burden Est. per Respondent: 2.5 Hrs.

Pursuant to section 54.405, all eligible telecommunications carriers (ETCs) are required to provide Lifeline service. In turn, these ETCs are permitted under section 54.407 (Lifeline) to receive support for offering Lifeline service to qualifying low-income customers. Pursuant to section 54.403(c), carriers providing toll limitation services (TLS) for qualifying low-income subscribers will be compensated from universal service mechanisms for the lesser of the incremental cost of providing TLS or up to $3.00 beginning April 1, 2012 and up to $2.00 beginning January 1, 2013; TLS support will no longer be available beginning January 1, 2014. Pursuant to section 54.413 (Link Up), ETCs that also receive High Cost support may be reimbursed for providing reduced-service connection charges to eligible residents of federally recognized Tribal lands. ETCs must use FCC Form 497 to request reimbursement for participating in the Low-Income Program.

Line 1 USAC Service Provider Identification Number (SPIN) - Please enter your 9-digit USAC Service Provider Identification Number.

Line 2 Study Area Code (SAC) - Indicate the 6-digit study area code for which you are claiming reimbursement.

Line 3 499 Filer ID - Enter the 499 Filer ID number of the filing entity. This code is assigned by the Commission's Data Collection Agent after a company files its first FCC Form 499-A.

Line 4 Technology Type - Indicate whether the ETC designated for the service area represented by the study area code on Line 2 provides service using wireline or wireless technology.

Line 5 ETC Type--Indicate whether your company was designated as an ETC for the limited purposes of offering Lifeline support only, or if your company is designated for both High Cost and Low income support.

Box 6 Organization Information - Indicate your company's legal name and mailing address.

Contact Name, Telephone Number and Fax Number - Provide information for the individual who should be contacted with questions about this form.

E-mail Address - Indicate e-mail address of contact person listed above.

Box 7 Filing Information

a)Submission Date - The date that you are filling out this form.

b)Data Month - The month for which you are reporting data. Please submit one worksheet per month.

c)Type of filing - Check "original" box if your company is reporting this data for the first time. If this is a revision to data originally submitted, check the "revision" box. Revisions will not be accepted later than 12 months after the data month for which the revision applies. Report originals and revisions on separate forms. For revisions, all amounts should be reported as positive numbers reflecting the actual amounts that should have been claimed for the month.

d)State Reporting - Indicate in which state the ETC is claiming support.

Lifeline:

Description: The federal Lifeline Program benefits eligible low-income subscribers by reducing their voice telephony service by $9.25 per month. Tribal customers may receive a reduction of up to $34.25 off their monthly local phone charge.

Non-Tribal Lifeline: All eligible, Non-Tribal subscribers will receive $9.25 in federal support.

Tribal Lifeline: Additional federal Lifeline support of up to $25 per month is available to eligible residents of Tribal lands, as defined in 47 C.F.R. section 54.400(e).

Line 8(a) Provide the number of low-income subscribers for whom Non-Tribal federal support is claimed.

Line 8(b) The maximum rate per subscriber is $9.25 for Non-Tribal Lifeline support.

Line 8(c) Enter the total dollar amount of Non-Tribal Lifeline support claimed (multiply Line 8(a) and Line 8(b)). Report this amount in whole dollars.

Line 9(a) Provide the number of low-income subscribers for whom Tribal federal Lifeline support is claimed.

Line 9(b) Enter the rate per subscriber for Tribal Lifeline support claimed, up to a maximum of $34.25.

Line 9(c) Enter total dollar amount of Tribal Lifeline support claimed (multiply Line 9(a) and Line 9(b)). Report this amount in whole dollars.

Line 10 Enter total Lifeline dollars claimed for the reported month. (Add Lines 8(c) and 9(c)). Report this amount in whole dollars.

FCC Form 497

April 2012 EditionLIFELINE WORKSHEETOMB Approval

3060-0819

Avg. Burden Est. per Respondent: 2.5 Hrs.

Toll Limitation Services (TLS):

Description: TLS includes toll blocking, which allows subscribers to block outgoing toll calls, and also toll control, which allows subscribers to limit in advance their toll usage per month or billing cycle. ETCs seeking TLS support must not distinguish between toll and non-toll calls in their service offerings for which the ETC seeks TLS support.

Support will be provided for the incremental cost of providing TLS up to $3.00 beginning April 1, 2012 and $2.00 beginning January 1, 2013. Support for TLS will no longer be available beginning January 1, 2014. Incremental costs include the costs that carriers otherwise would not incur if they did not provide TLS to a given customer. The incremental cost of TLS does not include the full retail charge for TLS that the carrier would charge other consumers. Moreover, joint and common costs associated with TLS are not supported by the Low Income support mechanism. In addition, Lifeline support in excess of the incremental cost of providing toll blocking will not be provided for switch upgrades.

Line 11 Enter the dollar amount for the incremental cost of providing TLS. The amount should not exceed $3.00 between April 1, 2012 and December 31, 2012, and should not exceed $2.00 between January 1, 2013 and December 31, 2013. Beginning January 1, 2014, TLS support is no longer available. Carriers may be asked for supporting documentation justifying the incremental costs of providing TLS claimed on this Worksheet.

Line 12 Enter number of eligible subscribers for whom TLS was provided.

Line 13 Enter the dollar amount of total TLS dollars claimed (multiply Lines 11 and 12).

Tribal Link Up:

Description: For an eligible resident of Tribal lands(as defined in 47 C.F.R. section 54.400(e)) a reduction of up to $100, to cover 100% of the charges up to $100 assessed for commencing telecommunications service an ETC that is also receiving High Cost support. Tribal Link Up also offers a deferred payment plan for charges assessed for starting service, for which eligible residents of Tribal lands do not have to pay interest for connection charges up to $200.

Tribal Land Low-Income Subscribers Only (available only to ETCs receiving High Cost support)

Line 14 Enter number of Link Up subscribers residing on Tribal lands (including any federally recognized Indian tribe’s reservation, pueblo, or colony including former reservations in Oklahoma; Alaska Native Regions; Indian Allotments; or Hawaiian Home Lands) for whom connection charges were waived.

Line 15 Enter the dollar amount of Tribal Link Up claimed per subscriber. The reduction in charges should not exceed $100 in total to cover 100% of the charges up to $100 for commencing service at the principle place of residence of an eligible resident of Tribal lands.

Line 16 Enter the dollar amount of Tribal Link Up claimed (multiply Lines 14 and 15).

Line 17 Enter the dollar amount of deferred interest (if applicable).

Line 18 Enter the dollar amount of total Link Up support (add Lines 16 and 17). Report this amount in whole dollars.

Line 19 This is the Total Low-Income Support amount to be paid to Eligible Telecommunications Carriers for the reported month. Enter the dollar amounts from Line 10 (total Lifeline support claimed), Line 13 (total TLS support claimed), and Line 18 (total Tribal Link Up claimed). Enter the sum of these amounts on Line 19. Report this amount in whole dollars.

Block 20 - Certifications and Signatures

Page 2 of FCC Form 497 requires the signature of an officer of the company certifying under penalty of perjury that the following statements are correct (as applicable):

Certify that your company will pass through the full amount of all Non-Tribal and Tribal federal Lifeline support for which they seek reimbursement, as well as all applicable intrastate Lifeline support, to all qualifying low-income subscribers by an equivalent reduction in the subscriber's monthly bill for voice telephony service or by offering a pre-paid wireless plan that includes a set number of minutes of use per month. See C.F.R. 47 sections 54.403(a)-(b)

Certify that your company is in compliance with all of the Lifeline program rules, and to the extent required, has obtained valid certifications for each subscriber for whom your company seeks reimbursement. See 47 C.F.R. § 54.407(d).

Certify that the data contained in this form has been examined and reviewed and is true, accurate, and complete.

FCC Form 497 support claims are due to USAC by the 8th of each month, or the next business day if the 8th falls on a Saturday, Sunday or federal holiday.

FCC Form 497

April 2012 EditionLIFELINE WORKSHEETOMB Approval

3060-0819

Avg. Burden Est. per Respondent: 2.5 Hrs.

Beginning October 8, 2012, ETCs that file their support claim electronically on FCC Form 497 for the previous month by the 8th of the current month will be paid for the previous month's claim by the end of the current month. ETCs that do not take advantage of electronic filing (i.e., those who file via fax, e-mail or U.S. mail) will receive payment for the previous month's support claim at the end of the following month.

Forms can be submitted electronically by visiting USAC’s website, www.usac.org, and selecting “USAC Forms.”

Forms may also be emailed to lifilings@hcli.universalservice.org, faxed to USAC at (866) 873-4665 Toll Free

(Attention: Customer Operations) or mailed to:

USAC

Customer Operations

2000 L Street NW, Suite 200

Washington, DC20036

NOTICE: To implement section 254 of the Communications Act of 1934, as amended, the Federal Communications Commission has adopted changes to the federal low-income programs. The Commission has expanded the availability of these programs and the level of funding for discounts to low-income customers.

The following worksheet provides the means by which eligible telecommunications carriers will be reimbursed by the Universal Service Administrative Company (USAC) for their participation in these programs. Failing to collect the information, or collecting it less frequently, would prevent the Commission from implementing sections 214 and 254 of the Act, would thwart Congress' goals of providing affordable service and access to advanced services throughout the nation, and would result in eligible telecommunications carriers not receiving universal service support reimbursements in a timely fashion. We have estimated that each response to this collection of information will take, on average, three hours for each respondent. Our estimate includes the time to read this data request, review existing records, gather and maintain required data, and complete and review the response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Washington, D.C. 20554, Paperwork Reduction Project (3060-0819). We will also accept your comments on the burden estimate via the Internet if you send them to PRA@fcc.gov. Please DO NOT SEND the data requested to this e-mail address.

Remember -- An agency may not conduct or sponsor, and a person is not required to respond to a collection of information sponsored by the Federal government unless it displays a currently valid OMB control number. This information collection has been assigned OMB Control Number: 3060-0819.

The FCC is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. If we believe there may be a violation or a potential violation of a FCC statute, regulation, rule or order, your worksheet may be referred to the Federal, state or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation or order. In certain cases, the information in your worksheets may be disclosed to the Department of Justice or a court or adjudicative body when (a) the FCC; or (b) any employee of the FCC; or (c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding.

If you do not provide the information we request on the form, the FCC may delay processing of your worksheet or may return your worksheet without action.

The foregoing Notice is required by the Privacy Act of 1974, Pub. L. No. 93-579, December 31, 1974, 5 U.S.C. Section 552, and the Paperwork Reduction Act of 1995, Pub. L. No. 104-13, 44 U.S.C. Section 3501, et seq.