20180716Custer Telephone Cooperative Inc Form 481.pdf

CTCI
Custer Telephone Cooperative Inc.
POBoxl24 . 1l0l t. MainAve Challis,lD 81226 . Telephone:[phone] . Fax:[phone]
July 16, 2018
ldaho Public Utilities Commission
Office of the SecretarvRECEIVED
JUL I 6 20t8Ms. Diane Hanian
Commission Secretary
ldaho Public Utilities Commission
472 West Washington Street
Boise, ldaho 83720
diane. hanian@puc. idaho.gov
Boise, ldaho
2018 Eligible Telecommunications Carrier (ETC) Annual Reporting Requirements
with the IPUC - Case Number GNR-T-1{-O1tl
Dear Ms. Diane,
Custer Telephone Cooperative, 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. Section 54.313 applies to eligible telecommunications carriers ("ETCs") receiving high cost
federal USF support and Section 54.422 applies to ETCs receiving low-income support. Both
sections require the Company to file the annual report with the FCC, USAC and the Commission. I
have also included the signed Affidavit pursuant to Commission Order 29841.
Company further requests the Commission to file the annual certification regarding federal
high-cost support with USAC and the FCC pursuant to 47 CFR 54.314(a).
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,
Dennis L Thornock
CEO / General Manager
//2il)
RE:
State of {&lbrO )
County ot tlxs\cy' I
)ss
AFFIDAVIT OF BUSINESS OR CORPORATE OFFICER
The ldaho Public Utilities Commission Order No. 29841requires that Eligible Telecommunications Carriers
ETC) 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+ost 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 Custer Telephone Cooperative, 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.l.am familiar with the Company's day-today 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. Custer Telephone Cooperative, 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. S 54.201(aX2).
5. I also certify that all federal universal service support funds received by Custer Telephone Cooperative,
lnc. during the current calendar year will be used in a manner consistent with section 254(e\: that is, for the
provision, maintenance, and upgrading of facilities and services for which the support is intended. The
company will continue to complyfor the period of Januayl, 2019, through December 31, 2019, 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.
cEo
Date:
CERTIFICATION BY ELIGIBLE TELECOMMUNICATIONS CARRIER
OF COMPLIANCE WITH SERVICE QUALIW AND CUSTOMER
PROTECTION, ABILITY TO REMAIN FUNCTIONAL IN
EMERGENCIES, AND USE OF FEDERAL HIGH-COST SUPPORT.
resid at [kut\i:.. Td.
SUBSCRIBED AND SWORN to before me this !b\!o"v or (.\t,
Notary Public
My Commission
Fo
F
1 t-
AUB
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Custer Telephone Cooperative, Inc.
472218ID1010
Voice Service Comparabilitv Certification
The Company certifies that the pricing of its voice services is no more than two standard
deviations above the national average urban rate for voice service of $45.38, as specified in the
most recent public notice issued by the Wireline Competition Bureau and Wireless
Telecommunications Bureau. I
I Wireline Competition Bureau Announces Results of'201SUrban Rate Sun,ey.for Ftxed Voice
and Broadband Senices and Posting of Suney Data and Explanatoryt Notes, Public Notice, WC
Docket No. 10-90, DA 18-1093 (rel. November 8,2017).
What is a telephone assistance program?
Financial assistance is available in Idaho to help qualified low-income individuals pay
for telephone or internet service. The Idaho Telephone Service Assistance Program
(ITSAP) offers a discount of $2.50 on monthly telephone bills. A separate program -
the Federal Communication Commission's Lifeline program (Lifeline) - offers a
discount of $9.25 on monthly telephone or internet bills. These programs provide a communication "lifeline" to those
who might not otherwise be able to afford telephone or internet service. They also enhance the value of service for
everyone by increasing the number of people who can be reached by telephone. A small surcharge is applied to every
Idaho telephone line each month to reimburse local telephone companies for the cost of state discounts under ITSAP. The
surcharge is waived for customers receiving the ITSAP discount. The Idaho Public Utilities Commission (IPUC) reviews
the surcharge annually and may increase or decrease the surcharge.
Who Is Eligible?
Any residential customer who meets program-based or income-based eligibility criteria may apply. To find out if you are
eligible call 866-255-708 1 .
The assistance provides the following discounts:
Landline phone:o Idaho Telephone Service Assistance Credit - $2.50o Lifeline FCC End User Charge Credit - $6.50o Federal Lifeline Credit - $2.75
lnternet:o Federal Lifeline Credit - $9.25
Wireless/cellular phone:o Wireless Federal Lifeline Credit - $9.25o Wireless ITSAP Credit - $2.50
Note: Custer Telephone does not provide wireless/cellular phone credits at this time. In addition, CTCI does not
offer credits on bundled service packages at this time.
How Do I Apply For Assistance?
. Apply by calling 866-255-7081.
o If you are eligible, your name, address and telephone number will be forwarded to Custer Telephone.r The monthly discount will begin on your next billing statement if your name, address and number match the
telephone company's records.
Do I Need To Apply Every Year?
Yes. Your eligibility must be renewed each year.
Lifeline and ITSAP are government assistance programs. The credits are non-transferable, only eligible consumers may
enroll in the program, and the programs are limited to one discount per household.
CTCI
Lifeline Service Terms
Custer Telephone Cooperative, Inc. is a quality telecommunications service provider which provides basic and enhanced services at
reasonable rates within its service territory. Basic residential telephone service is offered at the follouring rate:
Monthly Non-Recurring
Rates & Charges Charge
Single Party Residential Telephone Service
The following fees apply in addition to the above monthly rate:
$r 8.00 $ 18.00
o FCC End User Charge
o Idaho Telephone Service Assistance Program (ITSAP)
o Idaho Universal Service Fund (ID USF)
o Custer County 911 Fee
o Federal Excise Taxo Federal Universal Service Fundo Residential Access Recovery Charge
o FUSC- Residential ARC
Single Party Residential Telephone Service Total
Federal Lifeline Credit
Lifeline FCC End User Charge Credit
Idaho Telephone Assistance Program Credit
Idaho Telephone Service Assistance Program (ITSAP) Credit
Federal Excise Tax Credit
Federal Universal Service Fund Credit
Residential Access Recovery Charge Credit
FUSC- Residential ARC Credit
$6.50
$0.00
$0.2s
$ 1.25
$0.88
$ 1.20
$3.00
$0.55
$3 r.63
($2.7s)
($6.s0)
($2.50)
($0.00)
($0.88)
($1.20)
($3.00)
($0.5s)
Single Party Universal Lifeline Telephone Service Monthly Rate*$14.2s $18.00
*Discounted basic service rates and free Toll-Blocking are available to those that qualify for Universal Lifeline telephone service.
The above rates include the following:
o Unlimited Local Calling
o Touch Tone Capabilityo Access to Operator Serviceso Directory Assistance and Inter-Change Service Providerso Voice Grade Access to the Public Switched Network
o Free Access to 800 and 800-like Toll Free Services
o One Free Directory Listingo Free Access to a Business Office and Free Access to the Idaho Relay Service by Dialing 7l I
Emergency 911 Service.Surcharge for 9l I services is assessed according to government regulations.
Long Distance is not included. Long Distance rate is ten cents ($0.10) per minute or flat-rate plans are available.
Custer Telephone Cooperative, Inc. offers basic services to all customers in the following exchanges:
838-Clayon / 879-Challis I 876-May / 894-Elk Bend
Lifeline broadband only service: ** 10/lMb internet plan $69.95 - $9.25 Federal Lifeline credit: $60.95 Lifeline broadband only
monthly total
**FCC mandate requires at least 10/l Mb download/upload speeds unless not available in your area in which case the plan must be at
least a 4/lMb plan.
For additional detail on any of these services, please contact our business offrce at 208.879 .228 I or toll-free 866.879 .2281
Custer Telephone Cooperative, lnc.
4722781D6].0
Functionality in Emergency Situations
Pursuant to 47 C.F.R. I 54.313(a) (6) and/or 47 c.F.R 5 54.422(b) (4) as set forth in 47 c.F.R. S
5a.202(a)(21Custer Telephone Cooperative, lnc. (CTCI) is able to function in emergency situations for
both voice and broadband service.
CTCI has the following capabilities: Back-up power is provided to CTCI's central and or remote
office(s) by use of fixed generator and batteries that provide it with 120 hours of emergency power
service. ln addition, CTCI's field electronics have 8 hours of back-up power by use of fixed/mobile
generators and batteries. CTCI also has SO NET technology in its network that allows for self-healing
network should a fiber cut occur in its core network and will automatically reroute traffic. CTCI also has
two (2) redundant paths within its network to provide for the capability to reroute traffic. CTCI has
equipped its remote offices/and or field gear, with Emergency Stand Alone technology that will provide
for call completion and access to 911 in emergency situations. CTCI is capable of managing traffic spikes
resulting from emergency situations.
Custer Telephone Cooperative, Inc.
472218ID1030
Broadband Service Comparabilitv Certification
The Company certifies that the pricing of a service that meets the Commission's
broadband public interest obligations is no more than the applicable benchmark, as specified in
the annual public notice issued by the Wireline Competition Bureau.r Specifically, the
Cornpany's l0 Mbps down/ 1 Mbps up, unlimited usage broadband service rate is below the
relevant reasonable comparability benchmark of $88.13.2
1 Wireline Competition Bureau Announces Results oJ'201 SUrban Rate Sun,qt /br Fixed Voice
and Broadband Services and Posting of Survev Data and Explanatory- Notes, Public Notice, WC
Docket No. l0-90, DA 18-1093 (rel. November 8,2017).2Id.
472218tD30108
Custer Telephone Cooperative, lnc.
Study Area: 4722L8
Public lnterest Oblisation Certification
Pursuant to 47 C.F.R. S53.313(fX1)(i), CusterTelephone Cooperative, lnc. hereby certifies that it
has taken reasonable steps to provide upon reasonable request broadband service at actual speeds of at
least L0 Mbps downstream/1 Mbps upstream, with latency suitable for real-time applications, including
Voice over lnternet Protocol, and usage capacity that is reasonably comparable to comparable offerings
in urban areas, and that requests for such service were met within a reasonable amount of time.
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<ll!> Study A.0 ll.6r CUSTER ?EI, COOP .,
<020> Ftglram Ylar 20r 9
<Ofo> Cont ctll.m-Pt.FrUSACtltould@t rlr!$rdintlhltd.ll Dennis ?hornock
<035' Cstrctl.h!ho*,lmb.,'ttumb..dFr,$ntd.nldidind.t lim<010> 2O88335200 ext
{03$ cnr.cr G6dlAdd'*. fmril Add'rrol prrsld.nufind tn drr.llf,. <0ro) dgnni g@custertgl ' net
S€lect from lhe drop down menu or checl the boxe! below lo note complian(e wrth 54.113(fX1). Pr;vately held carriert mutl eogure compliance with th€
financial r€portintrequirementg5erforthin4TCFR543f3(fxz) lfurthercert'fythattheinformationreportedonthis{ormandinthedocument!
alta(hed below rr accurata.
Protrcsr R€pon on 5 Ya.r Plan
c'rrier cenifi$ !o 54.3r3(f,(1}(iiiI(300e1
(30roA)
(30108)
(30r2Al
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cartific.tion o{ Psblic lilcr.d Otlitttioor (4, cfR 5
54.313(fX1llil,
fhrta Provid. Att dl,trcnt
Conmunity Anchor hnitutions {47 CFR I
s4.313(0(rXrll
Ptcaia Providc Alta€hrocm
lr yqur aomprny. kir/ltllv |hld ROB Crnicr (47 CtR
0 s4.3r3('t:l)
It yer, doar l,olJr company lih thc BUt an6u.l rcport
PlGrs ch.d th$a borcr to coifinn tftrt tha
rtt drrd PDF, on linc 3ol 7, contrint th? nquirld
intomrtion gurrurnt to q :{.31r{fxzl €omplirn€.
rrquirlr:
Ehclronic copy of thcia annual i(,5 rcportt
loprntin3 n port tor TdGommnk tion,
Borrowcrrl
Oocumlnt&f sth 8.hnc. Sh..l, lncom? $tltcfilnt
.nd strtimcnt of cath Roui
It th. rasponra ii y.s on linc 3014, .l$ch your
6mprny'r iUS annual rapo.t rnd dl rrquirad
doqJrnantrlion
It thc .lrpotrlr ir no on lim 301d ir yoqr comprny
ruditad?
ll thr rarpotr* k yer oo liac 3018, ptrrre chld tha
borlr bclow to coofirm your Jubrtiltion on lint
3026 punurnt ro S !4.313(fl(2L cont.in::
Eith.r a coty ol thclr rudtcd tnrnchl strtcmat; or
l2l. nnrndrl ."port in r frolrut cotrptr.bl. to RUS
Op.ntinf RaFn fo. fchcomllrunhtticor BonomE
Docum"ntlrl fo. Sabnc shact, ln.ott!. Strtam?nt
rnd Sut m*ntof Crift Flovt
Manri.mant tGilar rnd/ot ,udit optnion i.tutd bY
thc in&pcndanr 66niird public rccount ot th.t
pcrformcd thc oroprny'r fimacirl rudit.
lf tha 1"tr0.r€ ir no on linc tol8, plc.rc check th"
boxrJ balow to cafifim your sutxtittion on linc
3026 pu6u.nt tog t4,313(llll, contrins:
Copy of fidr fiffinci:l stat.mlnt tvhich h.i b€to
subjlct rc rdiry by .n indtprtrdat ccnifi.d psbii(
.ccosnLnt or 2l a fin.ocill rcpott ln I form.t
comperrblc to EUS $Gr.thE ftaFort for
TGlacommffi krtbns Sorrorcrr
Undcdyint intorm.lion ,{bicctad to I tavitw by an
indapendonl ctrtitild public rccouo!.nt
Ir. . Atrreh &fri,lErt16
,rlemc of Atu.had oocumant Linlni Srqulrad
lr{drtratim
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clrtifiration.
(3025!oocurnanr{sl wirh &lancc $hcat lncom Slttamaol
rnd Strtrmrt el Crsh flffi
{3026} Att.ch th" rortdrc.t lrtina raquirld intomation ilamc ol Att|thid Docom€nt t sting Rsquirad
lnfomrdon
P.ar tl
lm$lwroltauo(,"l.rl*rnl.ill0ooffiIBr ;tcfmllf
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tf
ff
P{a l,
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Authorizrd Rurrl Bro.db.nd Cxpcrimlnt lRgt) r.cipi.ntr musl addrcsr the cc.titcrtior ,s psbk int.rert obl(artions .nd providc.
lnl ol ncrrly Scrvad communw anshot in3titutions.
Pu![c lnr.rGrt OblL.0oo3- FCC 1+98 (p.ttt pht 2F29, rtl
Pl.ai..ddrcs3 tine 4001 r{.rding compl,.ncc witi th. Commiltiot{s putllc htarcrt obl8etioo3. All ft8E particaprnt must providc .
,6ponre to Line 4001.
a{Xll. RcripiGot c.rtin.3 th.t it ir ofl?riog bro.dbrnd mcltiru th. rlguiratr puilk int.rart oblErtionr conrirtGnt with thr c.t.go.y to(
whirh thcy w.rr rrlact d, iocluditrt bro.dbild rpeed, hl.ncy, sr.gr caprcity, rnd 'rt r th.t.rc ri.ton.bly comp.r.ble to r.tcr lor
comparablc olfadnts ln urbln rrlar.
CommuoltyArdlor lnidt 6oot-KC l1l48lp.rrF.ph 79)
(n0a. RgE paiticiprras mui provida thr numbrr, nrm?s, tnd .ddrair.r ot carrllnunity in&ot inrtltutionr to
Ntlrhh thnv nilrdy drploy.d ko.dbind rcrui4 in thc prucedinS cdardar yaa.. qr thi. linq ple,3i r.lpond
lv?3 - rtlrch norv €ommunity .nchots, no * no n3w anchorsl to indkttr sh.th.. thb lirt rdll bN providcd.
lf y.s to l0O3A pl.rra prot lda. rat onri,ot tlo0tB'
ormot l{.ma ofAttach?d Documcnt lirtir8 Riquired loformation
crlendar yoar
P4c l!
{1061 iurd arordbrod trpatlnrnt Addttlo(nllroar&fftalbr
ofic!ilr(tbnrom OMt Control Nr. t0@Ogl6/OMl (onr.ol I'lo.
<O10t Study Arar Coda ..rrfr
<915, StudyAroaf,emc _ **
<020> Prolnm Ycrr rcrr
dr0, Contrct l{am? - Pct$n IrSAC $orrld cont ct t.3.rdill3 thir dat 8E.' reffi.
<Of$ cont ctfm.ilAddrcrs-Em.ilAddra3rof patsooH.nti8.dtndetrlipd3O: &,t&qr.r:.: il:
9*( la
<010>Study Ar€a Code
<015>Study Ar.a llrme
(030>Contrct lirme -(pnta€t
Number - Numbcr of in data lrne
<0391 Cootact p(r5on in
5005 Alarka Pho
(50t01 Ooyoupirticip.teintheAlast plan?(Yes/No)
150111
Pleasc indicate whrlher any terrestrial brdhiul or other satrllite backhaul becrmc
commercially available in the previour calender year ln .rear previously served
axelusively by perlormance-limiting $atellite backhaut.
(Yca/Nol
(sor2l
lf the filing carrier idenrified in its .pproved per{omance plans that it relies erclusively on
srtellile bacthaul for 3 certlln poriton of the population ln iB rervice area, indicetc whether
afryterfestr,al brckhaul o. other Satellite b8cthaul became €ommcfcially availabl€ in th!
previoius calendar year in areil that were previoiurly served exclusively by titellite beckhaul.
(Yer/Nol
<5013>
le.hlon C klh.{l lGidbfy
,.8( l(
lf{oll ab*. ?h{ frni.ifatl lltdiri,oml Oodrffi|llton
Oal. Cnlh(tlrn fffi Oirl Cootrol tto. 306&Ott6/OMl Cont,ol No. t06&Ot19
iHV&{d htbd or hpblbn
Pttn l7
(0t0> studyArcr Code {?r21,
<01t> Study Arc. Namt C-UsAAT TEL COOP
<020> Prgtram frrr 2 019
<O30> Cont ct Nam. - p.rton UsAq$ouldcontict rc8.dii
<035> Contact l?l.phona Numbct - NuBbet of peffon
<039> Conttcr [mril Addrcrs - Emrtl Addrast of paTton adantitied in dttr lina <030> dcffitsacusicrrc.I - ne!
TO 8[ COMPTETEO BY THE REPORIING CARRIER. I' THT REPORNNG CARRITR 15 FII.ING ANNUAL R€PORNNG ON IIS OWN EEHATF:
C.rtlficatlon of Ofllcsr ar to the Arcuracy of the Oata Reported tor the Annurl Reportint for CAF or Ll Recipients
I c.rtlfy th.t I rm i olf<cr ol rht rcponi4 fnicr; my ..3ponriulitlrt hdudc anfrtrt thc rccuracy ol th! rnnurl rapoda3 equhcmlntt lor uolvcrtd tcwlcc auppod
rGclplantt; rnd, lo thc ba3t o, ny tnou,lcq!, $r lnformrdon rGponcd on thit loflr rnd k! roy rrtachmcnB lr eccuntc,
[rtnc of RaFftini c.t;t' f,rrsTal trL cooP
iigratura of Au$orircd ofl'iclr: cEktlrIBD olrllrE oltc o?/lr/20le
Iri.tad ilrm! of Authorircd olficar: Dlmia Thotr*r
fitb ar p$ition of Authorircd offrcr: Ctrl"l Bxaculive OI t tct!
lclcphom nuobcr of Autho.irad otfi aar:'08 I t I 52 00 lxt
studv Anr fu& ot i.rcrtitrr crnier: '72214 FilirE Drrc 0atG ior thirform' 0?/16/2018
trffir uiltMh dEnt f.br ilri.mnr, m thir iom on bt psnirh.d !y fim d iorfrf,vr wd.r tht Commsk tbnt Ari o{ l9ta, a, U.s.C. tl tO2, 103{bl. o. fiil s loprimml
hdr, Titlc lt of tir Unild Strt r Codr, lE U.s.C ! 1001.
P.tc 17
OMB Conrol No. 1060{986/OMg Control Ho. }06OOBu
P.!! 18
<010> Study Ar.. Code r?22t8
<015> StudyAt.rN.ru costan TEL (!or
<g?0> P.ogrimYcar :01,
<030> Crntaat l{rma - Pa.ran USAC thould 6t ct rutrrdrn3 ttrt drt. . D*sair Thornoct
<0x3> conndt kphsmt{umblr.NumbGrotFriatridrnttfirdindrullnc<o3o> 20s0115'00 "xr'
<0t9) ContadEmrilAddmr!'EmallAddrcrrqrprr$onldanrifindindat lim<O!O> dqsisqcqt!.rc.I.ror
TO BE COMPLTTED BY THE RIPORTII{G CARRIE& IF AN AGC''IT 19 FIUNG AilNUAT REPORTS ON THE CARRIER'S BEHAIf :
Certific.tlon of Oflicer to Authorire.n Agent to file Annual Rc9ort3 for CAF o. Ll Rrciplents on 8ch.f o, Reporting Car.l€r
lc.'{'thd{il'iEo'A9.rt}l.&lhorit.dbtub'r{lllr.lnlntmtlonEpod.donb.h.llo{th.nFod'tc.ri.'.l
dro..,dfyttn1.m.non-...,orffikldud..muflnglh.lccU'rcyolt,[.nnu.ld.t,rrepoftinerqu.m0EP'oYld.dtolh..glho'it.d
a{ant md, to {r b.:t ot tlly fnosl.dir, !r rtpoib l'd ar.tt providad to lha ruitori:rd atmt }. .ccunt..
Nror o, A*ho.irad Asa.t:
l{ama ot Reporlim Carriar:
SigBtu.e ol Autho.irad Qfliccr:Date.
Pdn!"d..@ of Adho.i2.d Oftic".l
Iitl" d sritim ql Authorirrd Offcrr:
Tclcahoac numbcr of Authotir€d Otticer:
sludv Ara. Cod. of qrrorti/rt C.rrie,:Fili.{ Da Ortc for thit ,@m:
,rBnr sirlfu{v rutiol f.h. ltatcrentr on thit tom a h plobhrd by te or forlaitua urid6 thr Cmmnkrttut
^(t ot lg:ta, 47 U.5.c. lt 5o2, 103(bl, o. f6c or hnlrienlmt
undlr litk l8 ofttc Unn.d Strtcr Cad., lt U.S.C. t l00f
TO BE COMPLETED BY THI AUTHORIZED AGENT:
Certirlcation ol Atent Authorizcd to File Annual Rcports for CAF or tl Rcclpients on Behtlf ol Reportint Ca?rier
thc ditr rcpond hlraln b$ad oD drtl provldrd by tha rGronkf, o.d.r; aod, to Otc b6t ot my lmwLdta, tfi. ln orm.th. rrponrd h.reh 13 accur.t..
l,rare of RcsrliE Crrncr:
N.rc ot Authorircd Ar?rit Fi.6
s4fitsa ot Authsirad AScfit o. Employ?€ ol Atcor:Oatc.
NrM of Authorirad Arlht Emolovee:
lrtle o. msition of Authorircd Ar€nt o{ EmgloE oa Arcnt
TalGghon! numb€r ot Autho.itad Arqnt or Efi9lov€! of AEed:
Study A.c. Codr of ReBrting Cerrilr:Fih.{ Du. otic ,or thi, form;
Pcsl ril[!0y mtii! r.b. ltrtffitr s thl, fm oo ba prroirlxa !v fi$ or foriiltem uodrrth! [e-mail] Ad of 1.9:ta. 4, U.S.C. tl502, goIbt o,llN q ii}prismnt cedcr lalL
18olth. Utrl.d St tcr Codr, lt U.S,C. I lor.
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