20140701Cambridge Telephone Company FCC Form 481.pdf

July 1 ,2014
REC.ri\,j[f,
?CII\ JUL .I Pil 3: 38
Ms. Jean Jewell
Commission Secretary
ldaho Public Utilities Commission
472 West Washington Street
Boise, ldaho 83720
jean.jewel l@puc. idaho. gov
0ur?-T-t4-ct t
RE: 2013 Eligible Telecommunications Carrier (ETC) Annual Reporting Requirements
with the IPUC
Dear Ms. Jewell:
Cambridge Telephone Co., lnc. ("the Company") hereby provides copies to the ldaho
Public Utilities Commission ("Commission") of the filing to the Federal Communications
Commission ("FCC") and the Universal Service Administrative Corporation ("USAC") for
designation as an Eligible Telecommunications Carrier, in accordance with 47 U.S.C. 54.313
and 54.422. I have also included the signed Affidavit pursuant to Commission Order 29841.
Company, Study Area Code 472215, is a rural incumbent local exchange carrier (ILEC) as
designated by the FCC, and is eligible to receive federal universal service high-cost support
pursuant to the Code of Federal Regulations ("CFR"), Tltle 47, Sections 54.301, 54.305, and
Part 36, sub-part F.
Please review the attached filing and include Company in your Annual Use Certification
Letter to USAC and the FCC.
Please note the enclosed document contains confidential trade secret information that is
exempt from public disclosure pursuant to Section 9-340D(1), ldaho Code. Pursuant to Rule 67
of the Rules of Procedure of the ldaho Public Utilities Commission, the enclosed trade secret
information has been submitted on yellow paper and has been separated from the
non-confidential portion of the document.
lf you have any questions, do not hesitate to contact me directly.
Sincerely,?-*u9-<Richard Wiggins
Cambridge Telephone Co., lnc.
President
/
State of ldaho ) CERTIFICATION BY ELIGIBLE TELECOMMUNICATIONS CARRIER
) ss OF COMPLIANCE WITH SERVICE QUALITY AND CUSTOMER
County of Washington) PROTECTION, ABILITY TO REMAIN FUNCTIONAL lN
EMERGENCIES, AND USE OF FEDERAL HIGH-COST SUPPORT.
AFFIDAVIT OF BUSINESS OR CORPORATE OFFIGER
The ldaho Public Utilities Commission Order No. 29841requires that Eligible Telecommunications
Carriers certify that it is compliant with applicable service quality standards and consumer protection
rules; and ETCs must demonstrate the ability to remain functional in emergencies. ln addition, the
Commission must file an annual certification with the USAC and the FCC that all federal high-cost support
provided to ETCs within the State of ldaho will be used only for the provision, maintenance, and
upgrading of facilities and services for which the support is intended. Accordingly, the undersigned states
and verifies under oath the following:
1. I am an officer of Cambridge Telephone Co., lnc., an eligible telecommunications carrier for receiving
federal universal service support under section 214(e) of the Telecommunications Act of 1996 in the state
of ldaho.
2. I am familiar with the Company's dayto-day operations in the state of ldaho and with the State's
service quality standards and consumer protection rules as set forth in Commission Order No. 29841.
3. Cambridge Telephone Co., lnc. is complying with applicable service quality standards and consumer
protection rules of the Federal Communications Commission and the ldaho Public Utilities Commission.
4. I certify to the Commission that the Company is able to remain functional in emergencies as set forth in
Commission Order No. 29841 and in 47 C.F.R. $ 54.201(a)(2).
5. I also certify that all federal universal service support funds received by Cambridge Telephone Co., lnc.
during the current calendar year will be used in a manner consistent with section 25a@); that is, for the
provision, maintenance, and upgrading of facilities and services for which the support is intended. The
company will continue to comply for the period of January '1,2015, through December 31, 2015, to be
eligible for federal universal service fund support.
6. This verification and affidavit is provided to be the ldaho Public Utilities Commission to enable the
IPUC to certify to the FCC that federal universal service support received by the eligible carriers in the
state will be used in a manner consistent with Section 254(e) of the Telecommunications Act.
SUBSCRIBED AND SWORN to before me this 3O day of T^r. ZOl4
Public for Tdc.
Commission expires
ho , residins r, U)acair . ][d2--'L- Z-Otb
Date: June 30,2014
DANALYNNE MUNDEN
Notary Public
State of ldaho
POBoxEE
Cambridge ID 83610
June 19, 2074
VIA OVERNTGHT DELIVERY
Marlene H. Dortch, Secretary
Federal Communications Commisslon
Office of the Secretary
445 Lzth Street, S.W.
Washington, DC 20554
RE: Confidential Einancial Information Subject to Protective Order in WC
Doeket Nos. 10-90, 07-135, 05-337, 03-109, CC Docket Nos. 0l-92t 96-45, GN
Docket No. 09-51, trtIT Docket No. L0-208, Before the Eederal Cornmunications
Commission
Dear Ms. Dortch:
CamEfidge Telephone Co. Inc., a privately-held rate of return carrier
receiving high cost support, has electronically submitted ECC Form 481 to the
Comrni-ssion wlth redacted financial data and 5 year build out plan. Cambridge
Telephone respectfully provides the Commission with its eonfidential
financial data so thal all its reporting obligations are satisfied.
Cambridge, by its authorized representative, respectfully submits
confidential infornation in compl.iance with 4'l C.F.R. SS 54.313 and 54.422 ,under seal, as specified with the Protective Ordered adopted on Novenber 16,
2AL2 ("Protective Order") and also in conjuncLion with 47 C.F.R. SS 0.457 and
0.459. Further justification for this confidential filing is identified
below in accordance with 4'l C.E.R S0.459(b)
Canbridge Telephone reguests confidential treatment of certain information
submitted with its annual reporting requirementg as a privately-held rate of
retuxn carrier and high-cost reclpient in Docket No. L0-90. The confidential
information is reguired by 47 C.f.R. S 54.313(f)(2) and includes detailed
financial information that is competitively sensitive, Disclosure of this
confidential information would have a substantial negative i:opact on
Cambrldge Telephone. Such inforuration would not normally be made avallab1e to
the pubtlc for inspection because of the finaneiaL information and should be
afr,orded confidenti-af treatment under both 4 7 C.F.R. SS 0.457 and 0.a159;
47 C.E.R. S 049(b): Information provided by Carnbridge Telephone j-ncludes
specific information related to fl-nancial data and is subject to protectlon
for the following reasons:
47 C.F.R. S 0459(b)(1) Identification of the specific information for which
confidential treatment is sought;
Cambridge Telephone Co. requests that all finaneial data, Ioop/subscriber
counts and route mile data be treated on a confj-dential basls under Exemption
4 of the Freedom of Information Act. Cambridge Telephone Co. maintains this
l-nformation is confidential, competitively sensitive data not normally made
available to the public. Release of this information would have a substantial
negative competitive irnpact on Cambridge Telephone. The non-redacted version
of the cover Letter for Cambridge Telephone's submission and each page of the
file containing confidential inforrnation is rnarked, "CONFIDENTIAL FINANCIAL
INFORMATION SUBJECT TO PROTECTIVE ORDER IN WC DOCKET I.IOS. 10-90, 07-135, 05-
337, 03-109, CC DOCKET NOS. 0L-92, 96-45, GN DOCKET NO. 09-51, WT DOCKET NO.
10-208, BETORE THE EEDERAL COMMUNICATTONS COMMISSTON."
47 C.F.R. S 0459(b) (2) Identification of the Commission proceedlng in which
the-informati_on was submitted;
The information is being submitted in compliance with 4 7 C.E.R. S
54.313(f)(2) and is to be filed in !f,C Doeket No. L0-90. Privately held rate
of return carriers that receive high-cost support must cornplete the FCC Eorm
481- to incl-ude a full and complete annual support of the company's financial
condition and operations as of the end of the preceding flscal year (sections
of which Carnbridge Telephone Co. is requesting be afforded confidential
treatment) .
47 C.E.R. S 0459(b) (3) Explanation of the degree to which the information is
commercial or flnancial or contains a trade secret or is privileged;
The information designated as confidential is detailed financial information
ineluding a bafance sheet, income statement, cash flow statement that j.s
competitively sensitive information not normally released to the public.
Release of any of this commercial or financial inforrnation would have a
substantial negative eompetitive impact on Cambridge Telephone.
47 C.F.R. S 0459(b) (4)&(5) Explanation of the degree to which the information
eoncerns a service that is subject to competition and how disclosure of the
information could result ln substantial competitive harmiThis type of conmerci.al and financj-al infonnation is generally not subject to
routlne public inspeetion under the Commj-ssionrs rules (47 C.F.R. S
0.4-57(d)), demonstrating that the Commlssion already anticipates that the
release of this tlpe of information likely would produce competitive harm.
Release of the information designated as confidential would allow competitorsto become aware of sensitive proprietary information regarding the operation
of Canbridge Telephone's buslness and would cause Canrbridge telephone
substantial competitive harm.
47 C.P.R. S 0459(b)(6)e(?) Identification of measures taken by the Company to
prevent unauthorized disclosure: availabiLity of the information to the
public and extent of any prev3-ous disclosure of the information to third
parties;
Carnbridge Telephone treats and has treated the
included in this submissi-on as confidential and
disclosure to parties outside the Company. Anyto be submitted to a state regulatory authority
non-public information
has protected it from
financial informatlon reguired
has been
filed as confidential information, not available to the public, in accordance
with state rules and/or statutes.
47 C.f.R. S 0459(b)(8) JusLificatj-on of the period during which the Company
asserts that material shoul-d not be available for public disclosurei
CanQridge Tel-ephone cannot determine any date on which this informatj-on
should not be considered confidential. However Cambridge Telephone does
believe that thls information should be treated confidential for a minimum of
10 years.
47 C.F.R. S 0459(b)(8) Other infornation the Company believes may be useful
in assessing whether its request for confidentiality be granted;
Under appJ.icable Commission rules and court rulings, the information
designated by- the Company as confidential shoul-d be withheld from public
disclosure. Exemption 4 of the Freedom of lnformation Act protects
information that is commercial or financial in nature; obtained frorn a person
outslde government; and prlvileged or confidential.
As specified in the Protective Order, two copies of the redaeted confidentiaL
information are being filed simultaneously with the non-redacted confidentialinformation. The redacted information for this filing and each page of thefile where confidential information has been omitted is marked "REDACTED -
FOR PUBtlC INSPECTION"
Please feel free to contact me with any questlons regarding this particul"ar
matter.
Sineerely,
R,rLoJ il,fr tn.SRichard Wiggins
Canbridge Telephone Co., Inc
Pre3ident
Enclosures
.cc Mr. Charles Tyler, FCC Telecommunications Access Policy Division
<010> Studv Area Coda 11?275
Page 1
<015> StudyArea Name CNIIRIDCE TEL CO
1020> ProEram Year
<030> ConfeEt Name: Person USAC should contactwlthquisttonsaboutttrLUlii''--' Rtqhuit ntsgtu
<035> ContactTelephoneNumben 208e57131{ ut.
Number of thE person ldentlfled ln dela llne <030>
<039> Contact Emall Addressi
Emall of the person ldenHrled ln data llne <Olo> ills9ilrs'stcld!'coB
€2D Unfulfllled Servbe Requests (broadbandl
€30> Debll on Attemptg
<tl{XD Number of Complalnts per cugtome19
<410> Flxed<42O> Moblle
<5ilr,
<430> Number of Complalnts per 1000 cust!,mes (broadbandl<44o> Flxed IE3--l<45(D Moblle
.569, Servlce Quallty Standards & Consumer Protectlon RulesEompllance
servlce Quallty lmprovement Reportlng
OuF.Ee Reportlng (volce)
l-7-fi.-.heckbox lf notr:l
Unfulftlled Servlce Requestr
Debll on Attempts (volce)
Ctmpany Prlce offerlngs {broadband)
operatlng companles and Afflllates-
TrlbalLandofferlngslY/Nt? O O
Volce Servlces Rate
loE &ta ottorlEd wlthut,
,.o.rpr!E orlodEd Erbh.!t,
li./l,el ao hllplcczttl,m,/|ql
lauodGddselldildruimtt
(chcc\ to lndlort eilfi@llo,t
detqlbtdwwntt
l-:-ll--,i-t
r.?fl , I
<610>
<700>
<710>
<800>
<900>
<100tD
<1010>
[@npl',c sal,lhd wtutBtt
,@npkE ol odld lErbrrtrl,
lanryhl a otlodt d w ldqilt
lll yu, mpktc ottosh.t vafufuatt
ldBel€bfuGEedtt @l|f{tt
lon,d, d.ratptlvE doiln nil l/lW
<100>
<200>
<210>
<300>
<310t
I
0.0
,l
I
<110t> Terrestrlal BaclJraul (V/Nl?
<1110>
<120I> Terms and Condhlon for tllellne Customers
<2o(xb
<2005>
<3u00>
<3005>
Prlce cap Car{ers, Proceed to
lndudlng &ot*of-ReMm Cotlets affllloted wlth Ptlce Cop Loml Exchange Corrlers
ldEL lFhn/r!Eettlldlut
Jcafr!&l! rtrrtrd lslrtEr,l
RatE of Return carrlers, Procsed to@
leh.* lo ,I.dl@l ? n t l@tlmt
lffipk// onoEtuAw,bhal,
ll nor. cllrl to ttril@t2 R A@,/€Dl
lcnfu,,-arffiwrld,Etl
IcsrpLt oalo.,,dwl,hett
N
!JE!6&
coc
Juoaa,cuil
o!,
EIEz
Eg Ootr.!-:q 3*5 c2>iil9:ETIY
=EEuEiE E EEE5 E EEgs #E STE= Fi U E
E$E- tieHEg
EEI E E ?II E 5iEE[' E E E E E E3 UST 6 A F E P E
E[HE HEEEEEE
EEEl eE Ei EBE
IEH+ #EgsEgEglE-fr s-EEeer=
AAAAAArl914EFEdFtFldFtHHFlFlFldHvvvvvv
JE
trd
tLre 9 -'3
gHE 55.
5 E r *e!E{d gi:lr6 a> il rl O
BEE i}flHrr f H raEpl EflI;EfiE gEBE
*iE s$ rE
*EF, EHfiE
fr$EEEIEEEEipg_x.EiEE;EEEE:
eHHEEiEE
A.H
v
UUI!tE
EI
EEoi
EI
rt-tEldl'l
"ldtdIHI,l
fo
ot
d
l!!
or{H
o.EJo
U,cE
IUro
e,.9
.E
Eg
IJ
E
!,IU
dg
a,
s
lot
Eau
o
d
u
uCI4B6
x
omc!
Uc
E
EE
E.t,
UIE
coE
tro
UEl
o
h
e.oE
E
E1!l
I
d
:Et1'
o
Eu
u6coU
6mc,
!
5
n
F6at
o
ctmo
oc=6
EEc
tto
c!,!t
tro6
0,cl
o
oItE
=zI
!,,t)
E3z
o,Eo
o.
-goFtEcoU
tad!c,
EE
6h
I
Ix
.Eo
&
6
o!,la
GI
.EEEEtIotGcoU
==o
L'
6fcop
6'4
IoEEz
Uo
c,oL'
on3
G6
E
E!!6r
c,No
oU
Hk
E
B!t
d
3
0,EEz
EU
TI:lul
r{o
I
oEoIJ
Ed
!l
=ut
odo
a{
tU!,EE.
oU
Ja€{
E
B
H
E
6
oEE2EP
E
6
o
o!oUEa
E
q
o
o
mot!oL
0r
!qB
cFE
UE
go
!o
66 ..tE -.1!EgEo5tsUO>,!sbBU!cC
=
ourg
z!u
6
Tat
E
G
E
TUa!tJotJ
cg
s5thU
a
{(
(.l(
I
!
I(I
ts
E8
!hil utc
I
I
I
C
0!
Fo
trE
U
E
U
q
EE
oq
E&
0!
ilo
!
5
Fn
@o
&OE
fET5
EE
l*EEEoEo{u!
Ef,gE
g;
E6{-eBEE6
oo
dEEo
utoe|aA
Hgit EigE E<.Et
*EE5tE
UBil36=egoE
t
'!8-Ett
flii,t
E}EJ
EEq5i
3-€I!l
EEd
aa!I!!
a
n!
t
aF
1
!!.oErEJo!n
I!A
-!
a!3
aE
IE
tIIat
u
!!
A
Ig
o
oug
oaE6
nb
il
oIo
E6tc
at{
Eo!
Eo
t
ocdrtE
=d
EE
T
1t!
G
Er
I
oU
o6o
dU
EeUo
G
a
?
{
Eoo
Eaq
a.o
ET0u6L
go
dtEu
Eo
E
Eo
o
E4
Eou
Bg
3o
ts
oa
>oa
EoIJ6E
ioro
iE
de
Eou
tss3o
dHs
uaH
og
ocoEEo
oB
o6Eq!!EdU
oEdUUEEogDe
odE
omo
UEgo!s!-c
Eo:gEoEoE
o
uED
=oEB
pE€
DEE
uaEou
om?
!t
F6
Bs
ooo
g
.EIEt
=t!
EUE
Eo
oa
o
a&E3z
Lo.ll
E:z.{,co
trUdFuacoC'
hd6
qE
EE
I
E!E&Uc
Eotl
EEE
EfrEc
u6
ouE:o
nU
h
EoEoq
0
=Ez
u
coIJ
omI
Loo
EeEo
E
Aflo
o
EDzEd
1lEa
go
o13ouEe
E3
CIdo
uo!0oA
No!oEo.
0,
E:uo(]tt
-gog
oo
EIz
tu
o
iuU!oCIroE
T so'
frEE W
#EE-- b sHil fl Er€e : flE*iE € g E nHA
i;E E -**r *EE
EtEE*Ec*EEEEE
EEEEEf;EgiEEEE
**r# fiegggEEEEE
Ff EH EEEE66EE5$
EEEf; $ $U$$$B$$
co
El!
=o
co
EoE!D!0cU
tro
Ec
o
o(,
ol!
l-
oNgr
Id?ot4Uh
u
-E
'co
Ea,Es
d.ct
or{CN
=il
Eu,tEcoIJ
grdrct
E
.!T'u
uocou
=,fo
IIJ
vl
=troEoAI
0lEo
=ud
oL'
lnINct
h
o
6o,
E
EE!o&
oFIc,
oU
J
H
E
H
EU
rU
EtozE0L
1!)
r4
rlFlct
6d(NF
IU-E'o(J
oU
.r,3
ta
c,r-lo
oo0.Ba
60oEOt!o-
E
omct
o,tr
Eo!tr
.E,
q,IE
c(u!coeoclbog6
E!E
l!E3rt
gT!
F5
6
Aomc!
oE=6
E1'c
E[l
EoTI
Eo
oo
oLollEfz
I
ol!EazoEo
aooF
tsBcoU
mmo
8.ll
#EBoEr'lbFfiE E"nBEEaoI:gEr!cE5E969!tT' 5toEL
rgPErr.otsgo
E!Esfi9xts [n g5
f.E€! clg
EE
=+"6Eelt EG,t c,u6!EgEGs 3
oroilq$
=uro rot€ot!6!i.ohEA
haF6a9'
EEEfl.bob+uEiOo
*vaEn=EEtfi6Ix.EOt(!gUCEEEl -o-o-o
odrlFI
qI
EE
I
E!dtU
d
6
tgE'
l4
q
E
t!b!o
U,E
coUEIEo
EIJ
utfao6
!,r
a
rt
Eoz
ul!cotJ
omct
LE0i
E
Eh!oLo-
oNo
oo
dH
E
EH
Edo
oE.!z(ooL
t
ta
[t
F{o
cooE!t!IL
o!oL.lt!di
E'2
vt
or.lo
gl
o6!r!o.
EOE
Eg g E-EE E --' EE g is' f .cEE ,Ic- ts 5EA EE E EEE EB $ EE s Cg 0,CE 8* E E*ll E:i p EE p "=: e EgE pf E F:, a, trH t!:- q LU f !lE P .gb .E8,,' EE E EEE*gE=B9 ;E P E$E EE € fiEE g-E I Hs!- 6L n €EE EE E E
e*g Eg E E.[I*E
3;i= A A A#fiE il N flb-F V V V
o
ilrlo
=co
EdE
=UotE!ocUn
E!,.E
E6EE
ouo
Boii36oxo!o
ruE*uo
Uo
RUE
uou
uon
!dtu
U
I!
lLLl-:E
0,g6.C!0,3
Ji.
-o3!-o
&
.EJ
ctFINJ
clUo-oE=,g
J
cooooFouo
ouco
E
o(J
d
E!JF
trtFl
r.{
I
Eol
Ee!!so-
6No
E HE
oU
dF
U
8HddT
d
ql
E6z
IEoL
Eavt
ulHC)
6
fl
GI.ttoUoe
tl,
ut
or{o
6ron!l!o-
odorGA
co
E;s;EfEEUECE
ES$r-
OE:f:sEOH
EEi
dEH
Etg
= EFE* ".EE* gaepFsEE
UEOfsE d -Etr.!J
==E =E=t tg;
$$$$$$$$fi$$
d
E
i,u€
3o
d-6Eo
ua
tr
co
Ezt.E
oi,
!cE
Eo
!
o!o
6Bg
o
I
Eo
o
{
tIg
!Dq
EEEEu
q
E
€o
E
6
o4g5a
o
Eg
0
o
E
goEcoUroEE
aa
u::ol
!E
trt
il
Btr
I.!
oo
o44,
6t,
I
.,
6qC3
I
&
o
o
sa&4:
ca€&
0
nEi
tgcI
IcoEabE
o
edr.E
o
o
nIgE
BEouo6
a
3o
dA
cxsc
!tUq
IJ
o
o&Er
MmmEME
Ee
il
Eec;os!roGE.EfiJ
toE3ud6Eo
ug
ooEE2
co
e
.E
o
uc
Ec
=EEoU
Eu
P&
E
g
E
d6
T
A
u[truEu
u
E
E
MBEE
@$Eta EEit ggaE oiE
=tgEH55EIEqEEEI€BEEs8EbclEC
EC
=o!* ss Er EB I;- A E I
[gEEEgg E E !tsc I I r
E* E EE{EE g E:€
AE E EEE
iiigiE
-- o -na ! 6 6
oo d 6 d6m = m
E
E6
.s.E
EEEEes
.eE
EE
EE
Ets6t!sa
EE=E_66O6dd
Ei3ErE6d
EET:dE.9..rq
EE{deP€.EE
EEH
Er*"9!-E;te
E= e-,E5r
EgE'e83tr:
8dE
sFg
CEElfEEoa
E
-
Inl
_o!GEU'EE
:5EB
E?CTIU:qrEFIEE
Ei
s
oi
E
dc
.PTde?xI
SEEEla.!TI
E5TT
3tEeOEfP
E€E;€E
?T
=EBI!ig?
FEFT+E
E?FI
€.t
E.lrE
I-E
EE?t
ETls
ilfE.
iE
ag
E
8I
BtI{t
I5t
E
E
4I
E
E
5
E
Bc!I
E
!II€o
i$ i*t E g
ifr lgE E iE
i$iiEtEEE
EF EIF E$* E
EE lE? EEg f,
Ei EEE EEEE E
$j€ EgEEgiSE iH EBg E
!
!
eErd
EIF3sE
HEE| ,aft5
EHEE .*s: --d
EirEi ci
$FEIs€; =8
F
EE
EoEa;
.gsaEccE
E6
Eoo
Ee
=oEq
En
dB
E
Eo
Et
E!
ItcI
Bc!
It
!F
E
f,
E
E
n
!
I*
E
o
.lff
c
B
Et
.s
bfIi
E
Eo
6 ooE
<gltD StudvArerCodE
<018 StuthArea Nama CIItsf,IDCE TEI. CO
<0:l(!> ProEamYear 201ti
<03(b contsct NamE - PecDo USAC Ehould co$brt rErardlnr thls dib Itchltil tfimlB
<Gls> contactTeleDhonEltumber-NumberoflersonldefldlhdkrdaEllne<Btb 208?5?131{ elt.
<n$ Contact Emall Addres8 - EmB0 Addrels of Derson ld$tlned h date lha <Et{b Hl@lMe crcrel. . Ed
TO BE COMPLEIED BYTTIE EEPORTINC CARRIER, ]FTHE REPORIING CARRIER IS HL]NG ANNUALREPORTING OI{ IT5 OWN BEHATF:
Certlflcatlon of Offlcer as to tha Accuracy of tfie Dab Reportod Ior lhe Annual Reportlng for olF or Ll Reclptentt
aadq thlt I !n rn offier o[ tha raportlng anlsri my srlponrlbllhler lndudr rnsurlng tto rcarncy of the annurl rqortlnl rcqulrrmantr tor unhar5r] llrulca $ppqt
'6dplEntt, and, to thB tcrt oI my knorrledlg rhc lnformrllon reponed on thb frm rnd h ooy atladilBlnt3 lr lcarretr.
trmr trf nennr6n! r,Mlen tr IaERIDGB IEL CO
ilrnitura of Atnhortzed omcEn clElrrFtED olfllxilE Dara 06/te/?01a
rrktrd nEm€ of AuthorlEd OmG Rtchlra WtgglB
1tL oro63ltlon DfAuihorlzad Of,Im PrsldEnt
'deohonr numbs of AutfiortEd Of&pn 10825?0ea{ ul.
itudvArea Code of BeoDrtlnr carlEn {72115 Fllln! Du Detrfor th6165s 06/10/?011
undlfIurU olth! UnltrdSlats!c!dr. tB USC l lmt"
P.gr ll
{?tlltid!1b ShtdvAE.cndr
dllgr StudvArea ilame cAll&ErroB TEr. co
<rz(b PrEf,ramYeBr
<Et> conrdct Name - P€Eon TJSAC ilould contEd rElirdln8 thk &tt dcbarit UlqElr!
GOIS' CmbEtTeleohonel,lumbar-ll$|heroter!trlld€ntlfi:dlndebllne<03{b 20825?111{ lrl.
<Il9> clntictEmellAddrcs-EmallAd&rs:orpssonldell$Dldlndrtallne<tl30r Evloolnsaqrcrelr..otr
TO BE COMPIETED BY THE REPORTING CARRIER, IF AT{ ACENT ]S RUNG ANNUAL REPORTS ON IHE CARTTIERIS BSIAIF!
TO BE COMPI TED BVIIIEAUTHOBtrED AGENT!
Certllletlon ol Officerto Authorha En Atent to Flla Annualf,eports fo, CAF or Ll Redplentr on Sehrll of Reportln8 c8rilot
cerufy lhEt (Nsmo ol Ir &rlhortld to lubmll lh. lDt6mruotl ropodld on blhdt ol lh! ltporllng oE rlln I
rgsnB En4 t! lhs bcst ol my knawlodo!,li6 rrporlr [nd dnb pruvld€d lo lho lulhorlrrd rgrnl lr aeunlt.
lam! of Arthfiked AEents
l6ma of ReEortlnr canlcn
ihrutm of Authqlred omcen O!t!3
rrlnted nEmE of ArthorlEd Omen
nilE or oorltlon of Arlthalnd omc€r:
llephonr numbsr of AuhorlEd OmcEn
itudu fuF. code af nED6rlln! crrdE Flllnr lrrE nrtE far thh fahr
PlmatwllfullyrEldntbhriaturrlnlrontfbfoma[trDulrli.dbylneuf*fdtunundrth!Crmrrunlr{ioil4(tol1Sl4,4rU,'Clr50AlGlbLorllEorlmprBmmut
utrdlr'nrlt 18 slrh! unltrd tilg (!dG tt usc I iltrL
CErtlflcetlon o, ABEnt Author[ed io Fllr Annual Beporb forCAF or Ll Bedphnts on Bghalf of ReportlnE Cattlcr
he datl r.Foned hE eln bi!€d on drt0 prEuldld br lha reporrhg 6nlsi ilr4 to th! trtl of rrylootrhdlq thE lddmrdBr Ilplrtld harlh E rcsurEb.
lrmB of Authorltld A8qnt or Employqa of Alsnt:
ilamhru olAuthodrd AEentsr Emtloser ofASPnE Dat6!
lrlnmd nam ol AuthorlEd AEent or EmDlovee ofArEn!
:hlEa? DBldon of Aulhorl1ed ArBn!or Em9loYte olA8ent
lrlcntnna humbE. nl AuihdtEd AlEnt or EmolilEe of Alrnts
tlllnr Du! DatB fdfi ls fom3
18o[lh! Unll.d5ntE qod|, u t ]!c. I ts,.
oL
!EE
B
EGo
oq
o
e
a
6(
il
B(
fi6
Eil
ttq
h
u
a
Ed
Id ad
Co
E.o:EEEft0!ts!qEr!
EEagEEdE
0
o o
o
€o
6 E
E
c
o
ooE
U
Eavl
6ud
E
=oo
lrl
E
o
E
6
a
g
€do
E
g
E
o
G
o
oE
Etuog
aEE
3:
g
E
t4
oa
g
o
g
E
o
E
E
o
oa o
o
5;
ES{tSE8l^
IF
6
Er
6d
€F
hit
FoQ
6
q
d
o
E
0
qo
Fc
trE
E E ts E ht g s
U
EUufi
!L
c!Ci{tE
If,lIt
'l{I
5f)
9lselg
iH
EI[,
ET3oJ
tG55
{rtoIo)
To-{{fl,
H
dg
H
otrldrltr
HJ
!I
a eH oH AH tr 6 o
$o6
E_BE2Bg3
Eg.EEUEoo;HE.93;E!OB
=$Efrtr6.$o
E -s'GUI
AAoo
6Fo
o5
E
E1'sEoG
coEEIdo
o
Hgt!
;Eu
p
!!
a
EqtE
Eou
6mo
DId
r6dE6
omo
otr
EE!
.E
!@
trqE
o
otr
E
UoE:z
o!ea
oEo
BggtgEoIJ
Eo
!!
En
6EcIu
c
6
6!
EE€a3
d@otEEo
g
o
U
5ag
EU&IoEEz
uo
ou
I
?
Bo
e
EEor
CJo
ou
d
E
0
HHdg
U
@Eoz6o
!Eq
q
0!
EEo
tf
A
d
u
.EU
oU6udco!g edtguo:?
<F5
$E E6 UEa<5
€E
n
dtt
ridA!o
oC
E
d
3
!da
o
c!uttt
u'oIu3
I!
I
cI
!!
!,
'oog
Eia
fdn!o
{
E
Ed
1
t;Ifro
Bu
di{I
l{'o
!f
€
3
5,
u'df,o
oUctrfs
oE!-E65 re-
oo oo o
o c E
A
g
6
o
op
r
-sE
$E
E-ortOB\3
e o
d
o o o q o o
.gE
5HiEt.9
EEE o
I
o
E
ou o
I
0
oa
c
g
o
o o
a
I
EH8rocFr!ud
&u
6 I6{
nq
66
no
5
E6 6o 6
!on3uoE
Jl ,r o
o
o ao oo 6
c
0
o
q
o F
o
E!5s
EEE
6
q5
6
o o
6q
I
no
o
6
o
I
a
uB
oEEc
q
9qaU
u
coU
oEE
Leda
o
I
z
dt
cIoJ
,
1q5u
ocou
oEit
EU
!{
!
i
I
o
E gH aH 6H aH oH oH aH oH
H
sId
d
F6rlooN
aU
dots
EI
Tcfi
d
EEzdod
t
u
me
otoUEo