20210630Assurance Wireless Form 481.pdf

DOCKET NO. GNR.T.21.O1
Cover Sheet for Submission of
2021 Annual ETC Certilication Renorts
Name of Eligible Telecommunications Carrier:Assurance Wireless USA
USAC StudyArea Code: 47g0ls
Filing date: 6-29-21
Lifeline Only ETC? Yes or No Yes
Is this: Original submission?
OR
Yes
Revised /Augmented submission?
Person to contact for questions:
Name Tami Schwonek
Phonenumber 425-383-5551
E-mail address [e-mail]
Documents included in this filing (please check applicable items):
Affidavit for High-Cost Support
CAF/ICC Support (47 CFR $ 54.304)
\.\. Form48l
HUBB Portal Broadband Deployment Data
***If No, Affidavit must accompany first original submission
.,:;.- Iiti-i.Ii,i
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<010> StudvArea Code 479015
<015> StudyArea Name AaSurece flLreless IrsA t. P
<020> ProrramYear 2022
<030> Contact Name: Person UsAcshould contact
with questions about this data Tami Shronek
<035> ContactTelephone Number:
Number ot the person identitied in data line <030>
a253835551 qt
<039> Contact Email Address:
Email ot the person identified in data line <030>tili - ahrcneket -rcblle - cm
FormType 5a.422
Itzoot
1,""
Servlce OutaSe Reportlng (Volce)
follectlon Form
fCC Form 481
OMB Contrcl No. 3
Dec.mber2020
<010> Study Area Code 479015
<015> Study Area Name Assurance wileless UsA L. P.
<020> Program Year 2022
<030> Contact Name - Person USAC should contact regarding this data Tami Shvonek
<035> ContactTelephoneNumber-Numberofoersonidentifiedindataline<o3o> 42s3835ss1 ext
<039> Contact Email Address - Email Address of oerson identified in data line <030> tami . Ehuonek@t -rcbi 1e. com
<210> For the prior calendar year, were there any reportable voice service outages?
<22O> <a> <b1> <b2> <b3> <b4> <c1><c2><d><e><f>
Did This Outal
Affect Multipl
Study Areas
NORS
Reference
Numb€r
Outage Start
Oate
Outate Start
Time
Outate End
Date
Outage End
Time
Number of
Customcls Affected Total Number of
Customers
911 Facilities
Affected
fies / Nol
Service Outage
Description (Check
all that aoDlv)
Itloot
l*"
llumber of Gomplalnts per l1ll0 cilstornen
Collectlon Form
FGCFoffi48l
OMBGoffiol
Drcembcr 20,
<010> Study Area Code 479015
<015> Study Area Name Asaur&ce Wirelesa USA L-P
<020> Program Year 2022
<030> Contact Name - Person USAC should contact regarding this data Tami shwonek
<035>Contact Telephone Number - Number of person identified in data line
<030>4253835551 ext
<039>Contact Email Address - Email Address of person identified in data line
<030>
tami. ahrcnek@t-rcbiIe. con
<400>
Select from the drop-down list to indicate how you would like to report
voice complaints (zero or greater) for voice telephony service in the prior
calendar year for each service area in which you are designated an ETC for
any facilities you own, operate, lease, or otherwise utilize.
<410> Complaints per 1000 customers for fixed voice
<42O> Complaints per 1000 customers for mobile voice
<010> StudvAreaCode 479015
<)ti> S&dyArea Neme lrrnrlaDce ritelass IXIA tJ.E.
O20r Pfofr,rmYear 2o,lt
<Ogo> C$tact Namc - P.rson USACsllould csntrrt remrdll|r thls data Ta01 shjroDck
<0!t5> conact Telcollonr Number - llunrber oJ Eerson ldentffed ln dao lin <)!tD '253435551
a:'L
<oiltr, Coutact Emall Addr66 - EmellAddresi sf Bersori ldendfi€d ln drE llne <)3F t rt.sLroac&lt{irr11s.cor
615> Certfy compllance wlth apdbue mlilmum sarvle standar*
<010> StudyArea Code 479015
<015>Area Name
<020>Year
<030> Contact Name-USAC should contact thls data Tami shrcnek
<035> Contact Telephone NUEEI:l'lurnleloffgEgn identified in data line <030>4253835551 exts
<039> Contact Email Address - Email Address of person identifted ln data llne <030>taoi - ahmn6kat-rcbi1e. c@
<6@> Certifu compliance regarding ability to function in emergency shuations
<510> Descriptive document for Functionalhy in EmerSency Situations
(8fl1) Operatlng Companles
Data Collection Form
FCC Form 481
OMB Control No. 3060
December 2020
<010> Study Area Code 4?901S
<015> Study Area Name Assurance Wireless USA L.P.
<020> Program Year 2022
<030> Contact Name - Person USAC should contact resardins this data
<035> Contact Telephone Number - Number of person identified in data line <030> 42s383sss1 ext
<039> Contact Email Add ress - Email Address of Derson identified in data line <030> rami . shwonek@t -mobi.re . com
<810> ReportingCarrier Assurance Wireless USA. L.P
<811> Holding Companv T-Mobile USA Inc
<812> OperatingCompany Assurance wireless usA, L.P
sAc
red workshee
<813><a1>
Affiliates
<a2>
Doing Business As Compan
ee
<)il> StudvAreacode {79015
<)15> StudyAreaName Asrulance llLreleis USA IJ.P
<)20, Pro6amYear 2022
<030> Contact
<)35> Cortact Tdephone Number - Number of person idertificd ln data line {)30>
Taml ghsoaek
<)39> contact Emall Address - Email Address of Derson identlf,ed ln data line d3(D tml. - shsnekat -lEbile . cm
<900> Does the filing entity offer tribal land services? (Y/N)
<91D Tribal Land(s) on which ETC Serves
<92D Trlbal Government En8agement Obllgation
lf your company seryes Trlbal lands, please select (Yes,Nq NA) for each these boxes
to confirm the status described on the attached PDF, on line 92Q
demonstrates coordination with the Tribal government pursuant to
S 5a3l:l(aXS) includes:
<921>Needs assessmentand deployment planning wlth a fucris on Tribal
community andtor instifu tions.
Feasibility and sustainability planning;
Ma*eting services in a culturally sensative manner;
Compliance with Rights of way processes
Compliance with Land Use permitting requirements
Compliance with Facilities Siting rules
Compliance with Environmental Review procetses
Compliance with Cultural Preservation review processes
Compliance with Tribal Business and Licensing requirements.
Name of Attached Document
<922>
<923>
<924>
<925>
<926>
<927>
<928>
<929>
Sel.ct
Yes or No or
tlotAppllcable
.,'l r i i
<010> Study Area Code 4?9015
<015> StudyArea Name As3raEe lllrelc3s USA L.E.
<020> Program Year 2022
<030> Contact Name - Person USAC should contact reEarding this data TanL sbrcnek
<035> Contact Telephone Number - Number of person identified ln data line <030> {2s383sss1 *E
<039> Contact Email Address - Email Address of pe6on identified ln data line <030>tili - shrpnekot-fEbile. ffi
<1q)o>Voice services rate comparability certification
<1010>Attach detailed description for voice services rate
comparability compliance
<1020>Broadband comparability certifi cation
<1030>Attach detailed description for broadband
comparability compliance
Name of Attached Document
Name of Attacheal Docunrent
<010> StudyArea Code 479015
<015> StudyArea Name Aasuruce *ircless USA Ir. P.
<020> Program Year 2022
<030> Contact Name - Person USAC should contact regardlngthis data Tinl shMnat
<035> Contact Telephone Number - Number qL pqrson identifled in data line <03D .2s38355s1 e,(r.
<039> Contact Email Address - Email Address of person identified in data line <030> Effir..hmnekot-ooblle.cm
<110D Certify whether terrestrial backhaul options exist (Y/N)
<1130> Please select ffre approprieto rcponse (Yes, No, Not Applicable) to confirm the
reporling canier ofiars broadband servioe of at least 1 Mbps downsbeam and 256 kbps
upstream wiffrln fie supported area pursuantb $ 54.313(g).
<1140>Alaska Plan rate-of-return certification (yes, no, or not applicable) of
compliance with approved performance plan.
<010> StudyArea Code 479015
<015> StudyArea Name Asauraca flireleEs USA L.P.
<02D ProgramYear , du,
<03D Contact Name - Person USAC should contact recarding this data
<035> Contact Telephone Number - Number of person identified in data llne <03D 4253s3sss1 sE
<039> Contact Email Address - Email Address of person identifled in data llne <030> rill.sbmnekcr-mbile.cm
<1210> Terms & Conditions of Voice Telephony Lifeline Plans
<L220> Link to Public website
"Please check these boxes below to confirm that the attached document(s), on line 121O
or the websfte listed, on line 1220, contalns the required information pursuant to
5 5a.a22(aX2) annual reporting for ETG receiving low-income support carriers must
annually report:
<t227> lnformation describing the terms and conditions of any voice
telephony seMce plans offered to Lifeline subscribert
Name Document
HTTP httpa : / /ww. assurscfflrelaBa, cm/legal /term-ad-coadltloDa
<1222> Details on the number of minutes provided as part of the plan,
<L223> Additional charges for toll calls, and rates for each such plan.
E
{79015
<015> StudyAreaName Asrurilce rlre1e85 usA r,.P.
<020> Prorram Year 2022
<030>should contact this data
<035> ContactTelephone Number- Number ofperson identiffed in data line<030>
Tmi Sbrcrek
<039> Contact Emall Addresr- Emall Addressofperson identlfied ln data llne <030> tani.shrcneko!-noblle.cm
Select the appropriate responses below (Yes, No, Not Applicable) to note compliance as a reciplent of frozen High Cost s
to ofBet access charge reductions, and Connect America Phase ll support as set forth in 47 CFR 54.313(c!,(dl,(e). The inf
form and in the documents attached below is accurate.
<2015> 2016 and future Frozen Support Certification 47 CFR I5a.313(cXa) f
Price Cap Carrier Connect America ICC Support (47 CFR S 54.313(d))
<2016> Certification support used to build broadband
Connect America Phase t! Reporting (47 CFR S 54313(el)
<2Ot7A> Connect America Fund Phase ll recipient?
<2OL7C> Total amount of Phase ll support, if any, the price cap carrier used for
capital expenditures in 2018.
<2018>Attach the number, names, and addresses of community anchor
institutions to which the carrier newly began providing access to
broadband service in the preceding calendar year - 54.313(eXlfiii)(A)
Connect America Phase ll - FCC Form 470 Postings
<2019> For the filing due July 1 following full implementation of this requirement,
answer yes, no, or not applicable to this certification request
Name of Attached Document Listing
Required lnformation
I
<010> StudyArea Code 4790t5
<01$ Study Area Name Asgurance l{ireless
<020> ProgramYear 2022
<03D Contact Name - Person USAC should contact regarding this data Tami Shwonek
<03$ Contact Telephone Number - Number of person identified in data line <030>4253835551 ext.
<039> Contact EmailAddress - EmailAddress of person identified in data line <030> tami . Shwonek@t -mOt
(3007)Does this filing retain a Cost Consultant and/or Firm, or other Third Party to prepare financial and
operations data disclosures submitted to the National Exchange Carrier Association (NEC,A), USAC,
or the Administrator?
ilame ofGonsuhant Name of Consuhant
<010> Study Area Code 4'7 qO1 q
<015> Study Area Name Assurance Wireless USi
<020> Program Year 2022
<030> Contact Name - Person USAC should contact regarding this data Tami Shwonek
<035> Contact Telephone Number - Number of person identified in data line <030> 4253 g 3 5 5 5l- ext .
<039> Contact Email Address - Email Address of person identified in data line <030>tami . shwonek@t -mobi Ie
Select from the drop down menu or check the boxes below to note compliance with 54.313(f)(1). Privately held carrier
financial reporting requirements set forth in 47 CFR 54.313(fX2). I further certifi/ that the information reported on this
attached below is accurate.
Progress Report on 5 Year Plan
Carrier certifi es to 54.313(fXlXiii)
(300e)
(3o1oA)
(3010B)
(3012A)
(3012B)
(3013)
(301s)
(3015)
(3017)
(3014)
Certification of Public lnterest Obligations {47 CFR 5
s4.313(fx1)(i))
Please Provide Attachment
Rate-of-Return Community Anchor lnstitutions
lndicate if the carrier newly deployed broadband
service to community anchor institution(s) in the
previous calendar year.
Please Provide Attachment
Using link, download template and list the number,
name and address for each community anchor
institution. Attach the document which contains the
community anchor institution details as required by
47 C.F.R. 5 s4.313(fXl)(ii)
ls your company a Privately Held ROR Carrier {47
cFR S s4.313(fx2))
lf yes, does your company file the RUS annual report
Please check these boxes to confirm that the
attached PDF, on line 3017, contains the required
information pursuant to S 54.313(f)(2) compliance
requires:
Electronic copy oftheir annual RUS reports
(Operating Report for Telecommunications
Borrowers)
Document(s) with Balance Sheet lncome Statement
and Statement of Cash Flows
lf the response is yes on line 3014, attach your
company's RUS annual report and all required
documentation
lf the response is no on line 3014, is your company
audited?
lf the response is yes on line 3018, please check the
hawac halarrr ta aanfirm rrar rr er rhaiccian an lina
Name of Attached Document Listing Required
lnformation
Name of Attached Document Listing
Required lnformation
(Yes/No)
(Yes/No)
Name of Attached Document Listing Required
lnformation
oooo
(3018)(Yes/No)oo
4?9015
Fln nclal Data Summ.ry
(3027) Revenue
(3028) Operating Expenses
(3029) Net lncome
(3030) Telephone Plant ln Service(IPIS)
(3031) Total Assets
(3032) Total Debt
(3033) Total Equity
(3034) DMdends
tlrm of Att ch.d Documnt L&tllt R.quhtd lnformtbn
<010>Study Area Code i[79015
<015>Study Area Name Assrdce $.releas USA L-P
<020>Program Year 2022
<030>Contact Name - Person USAC should contact regarding this data TatrL Sbrcn€k
<035>
<039>
Contact
Contact Email Address - EmailAddress of person identified in data line <030>tmi . ahrcrckat-rcbile. cm
Number - Number of identified in data line <030>
{(Xl5 Rural Broadband Experlment
Authorized Rural Broadband Experiment (RBE) recipients must address the certification for public interest
obligations and provide a list of newly served community anchor institutions.
Publlc lnterest Obllgations - FCC 1tt-98 (paragraphs 2&'29, 781
Please address Line 4001 regarding compliance with the Commission's public interest obligations. All RBE
participants must provide a response to Line 4001.
4fi11. Recipient certifies that it is offering broadband meeting the requisite public interest obligations consistent
with the category for which they were selected, including broadband speed, latency, usage capacity, and rates that
are reasonably comparable to rates for comparable offerings in urban areas.
RBE Communlty Anchor lnstitutions
<4003a> lndicate if the carrier newly deployed broadband service to community anchor institution(s) in the
previous calendar year
<4003b> Please Provide Attachment: Using link,
download template and list the number, name
and address for each community anchor
institution. Attach the document which contains
the community anchor institution details as
required by FCC 14-98 (paragraph 79)
Name of Attached Document Listing Required lnformation
(50051 Alaska Plan Participants Additional Dodmentation
Data Collection Form
FCC Form 481
OMB Contro! No. 306
December 2020
<010>Study Area Code 4'7901-5
<015>Study Area Name Assurance wireless USA L.P
<020>Program Year 2022
<030>Contact Name - Person USAC should contact regarding this data Tani shwonek
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>taai . shwonek@t -mobile . com
5005 Alaska Plan
(s011)
(s012)
Please indicate whether any terrestrial backhaul or other satellite backhaul became
commercially available in the previous calendar year in areas previously served
exclusively by performance-limiting satellite backhaul.
lf the filing carrier identified in its approved perfomance plans that it relies exclusively on
satellite backhaul for a certain poriton of the population in its service area, indicate whether
any terrestrial backhaul or other satellite backhaul became commercially available in the
previoius calendar year in areas that were previoiusly served exclusively by satellite backhaul
<a>
Description Of Backhaul Technology
(Yes/Nr
(Yes/Nc
Newly Served Loc
<5013>
Date Backhaul Available
<010>Study Area Code 479015
<015>Study Area Name AgBurance Wireleaa USA L.P
<020>Program Year 2022
<030>Contact Name - Person USAC should contact regarding this data Tami Shwonek
<035>
<039>
Contact T hone Number - Number of n identified in data line <030>
Contact Email Address - Email Address of person identified in data line <030> [e-mail]
<6010> Enter the total amount of Phase ll Auction Support, if any, the carrier used
for capital expenditures
Phase ll Auction and New York Funds Certification
<6011>Certify (either yes or no) regarding whether the recipient has available
funds for all project costs that will exceed the amount of support that will
be received for the next calendar year. This certification must be provided
starting the first July lst after receiving support until the recipient's
penultimate year of support
Phase ll Auction Community Anchor lnstitutions
<6012a> lndicate if the carrier newly deployed broadband service to community
anchor institution(s) in the previous calendar year
<6012b> Please Provide Attachment Using link, download template and list the
number, name and address for each community anchor institution.
Attach the document which contains the community anchor
institution details as required by FCC 14-98 (paragraph 79)
Phase l! Auction FCC Form 470 Postings
<5013>For the filing due July 1 following full implementation of this
requirement answer yes or no to this certification request
Phase ll Auction Post-Final Deployment Milestone Performance Certification
Starting the first July 1st after meeting the final service milestone, certify
(yes or no) that the Phase ll-funded network that the Phase ll auction
recipient operated in the prior year meets the relevant performance
requirements in 5 54.309
(Yes/No)
Name of Attached
Document Listing Required
lnformation
<6014>
<010>Study Area Code 479075
<015>Study Area Name Aasuranee l{1re1a68 UsA L. P
<020>Prosram Year 2022
<030> Contact Name - Person USAC should contact regarding this data rili shmek
<039>Contact EmailAddress - Email Address of person identified in data line <030>tami . BhrcDekot-rcblle. com
<7010> Phase !l Auction recipient performance requirements certification (Yes/No)
(8(X15) Uniedo a Puerto Rico Fixed and Mobile Funds Certification
Data Collection Form
<010>Study Area Code
FCC Form 481
OMB Control No. 306tri
December 2020
4't 9015
<015>Study Area Name Assurance Wireless USA L.P
<020>Program Year 2022
<030> Contact Name - Person USAC should contact regarding this data rami shwonek
<039>Contact Email Address - Email Address of person identified in data line <030>tami - shwonek@t-mobi1e. com
<8010>
<8011>
<8012a>
<8012b>
<8013>
Uniendo a Puerto Rico Stage 2 Fixed - Capital Expenditures
Enter the total amount of Uniendo a Puerto Rico Stage 2 fixed support, if any, the
carrier used for capital expenditures.
Uniendo a Puerto Rico Stage 2 Fixed - Available Funds Certification
Certify (either yes or no) regarding whether the recipient has available funds for all project
costs that will exceed the amount of support that will be received for the next calendar
year. This certification must be provided starting the first July 1st after receiving support
until the recipient's penultimate year of support.
Uniendo a Puerto Rico Stage 2 Fixed - Community Anchor lnstitutions
lndicate if the carrier newly deployed broadband service to community anchor institution(s)
in the previous calendar year.
Please Provide Attachment
Using link, download template and list the number, name and address for each community
anchor institution. Attach the document which contains the community anchor institution
details as required by 47 C.F.R. I 5a.313(eX2)(A). Allowable File Types.
Uniendo a Puerto Rico Stage 2 Fixed - FCC Form 470 Postings
For the filing due July 1 following full implementation of this requirement answer yes, no, or
not applicable to this certification request.
Name of Attached
Document Listing R'
lnformation
<8014>Uniendo a Puerto Rico Stage 2 Fixed - Post-Final Deployment Milestone Performance Certification
Starting the first July 1st after meeting the final service milestone, certify (yes or no) that the
Uniendo a Puerto Rico Stage 2-funded network that the Stage 2 recipient operated in the prior
year meets the relevant performance requirements in 5 54.309.
<8020>Uniendo a Puerto Rico Stage 2 Fixed - Support Reimbursement Certification
54.313(n): Recipients of Uniendo a Puerto Rico Fund Stage 2 fixed support shall certify that
such support was not used for costs that are (or will be) reimbursed by other sources of
support, including of federal or local government aid or insurance reimbursements; and that
support was not used for other purposes, such as the retirement of company debt unrelated
to eligible expenditures, or other expenses not directly related to network restoration,
hardening, and expansion consistent with the framework of the Uniendo a Puerto Rico Fund
<8030> ! lniaada a Drrar.ta Diaa Cl:aa ? Eivad - Fliarclar Dranaradnacc anll Dacnanca l.laarrmanfalian
(90051 Connea USVI Fixed and Mobile Funds Certification
Data Collection Form
<010>Study Area Code
FCC Form 481
OMB€ontrol 1{o. 3O6G
December 2020
47 907s
<015>Study Area Name AEsurance Wireles6 USA L-P
<020>Program Year 2022
<030>Contact Name - Person USAC should contact regarding this data Tami Shwonek
<035>Contact Telephone Number - Number of person identified in data line <030>4253835551 ext
<039>Contact Email Address - Email Address of person identified in data line <030>tami. shwof,ekot-mobile. coh
<9010>
<9011>
<90t2a>
<9012b>
<9013>
Connect USVI Stage 2 Fixed - Capital Expenditures
Enter the total amount of Connect USVI Fund Stage 2 fixed support, if any, the carrier used
for capital expenditures.
Connect USVI Stage 2 Fixed - Available Funds Certification
Certify (either yes or no) regarding whether the recipient has available funds for all project
costs that will exceed the amount of support that will be received for the next calendar year
This certification must be provided starting the first July 1st after receiving support until the
recipient's penultimate year of support.
Connect USVI Stage 2 Fixed - Community Anchor lnstitutions
lndicate if the carrier newly deployed broadband service to community anchor institution(s)
in the previous calendar year.
Please Provide Attachment
Using link, download template and list the number, name and address for each community
anchor institution. Attach the document which contains the community anchor institution
details as required by 47 C.F.R. 5 54.313(eX2Xi)(a).
Connect USVI Stage 2 Fixed - FCC Form 470 Postings
For the filing due July 1 following full implementation of this requirement answer yes, no, or
not applicable to this certification request.
Connect USVI Stage 2 Fixed - Post-Final Deployment Milestone Performance Certification
Starting the first July 1st after meeting the final service milestone, certify (yes or no) that the
Connect USVI Fund Stage 2-funded network that the Stage 2 recipient operated in the prior year
meets the relevant performance requirements in 5 54.309.
Connect USVI Stage 2 Fixed - Support Reimbursement Certification
54.313(n): Recipients of Connect USVI Fund Stage 2 fixed support shall certify that such support was
not used for costs that are (or will be) reimbursed by other sources of support, including of federal
or local government aid or insurance reimbursements; and that support was not used for other
purposes, such as the retirement of company debt unrelated to eligible expenditures, or other
expenses not directly related to network restoration, hardening, and expansion consistent with the
framework of the Connect USVI Fund.
Name of Attached
Document Listing
lnformation
<9014>
<9020>
Connect USVI Stage 2 Fixed - Disaster Preparedness and Response Documentation
PaBe 21
<010> StudyArea Code 479015
<015> StudyA.ea Name AaaEace Wlreless USA L. P
<02D ProgramYear 2022
<030> Contact Name - Person USACshould contact resardingthis data Tami Shrcnek
<035> Cont.ctTelephoneNumber-Numberq[Ieq9!!4lqlifiedindataline<03D 'l2s383sss1 ext
<039> Contact Email Address - Email Address of person identified in data line <030> rani . sh*onekor-rcbit e. com
TO BE COMPLETED BY THE REPORflIiIG CARRIER, IF THE REPORTIf{G CARRTEN F FILI]TG AI{NUAL REPORMNG ON ITS OWt{ BEHALF:
Certlficatlon of fficer as to the Accuracy of the Data Reported for the Annual Reportlng for CAF or Ll R.clpients
I cartfy th.t I rm an oficer of thc rcportn3 carrlcri my rcsponslbllltler lncludc Gnrurlnt tfia rccuracy of ttr rnnurl raportln! requlramanG for unhrersal sawlce nrpport
racipicntsi and, to tha bc3t of my knowled8c, tha lnformrfion rcportcd on thls form and ln rny rttachmcnts ls accu6te.
NameofRemrtinECarrier. Aagurance Wireless USA L.P
iicnatureofAuthorizedofficer: CERUFTED ONLTNE Date 06/2s/202t
Printed name of Authorized offcer: Larry weians
nfle or msitlon of Authorized ofiicer: vice Presidenc
teleDhone numberof Authorized fficer' 9137941452 ext
itudy Area code of ReDortinp Carrier: 479015 Filing Due Date for this loJfii 01 / ot/ 2027
Persns willfully makint f.ls strtemrnts on thls form en bc punlsh.d by tine or torf.lture undcr the Communi@tions Act of 1934, 47 U.s.c. 95 502, 503(b), or finG or impri$nmcnt
und.r Titl. 18 ofth€ unitad st!t6 code, 18 u.s.c. 5 1001.
Page 21
PaEe 22
Certiflcation - ASent / Carrier FCC Form 481
oMB Control No. 3O6r(HBs6/OMB Gontrol No. 31F0.(,819
Dcccmbcr 2020
Data Colhct'ton Form
<010> StudyArea Code 479015
<O2O> profram year 2022
<030> ContactName-PersonUSACshouldcontactregardingthisdata Tami shwonek
<035> contactTelephoneNumber-Numberofpersonidentifiedindataline<o3o> 4253835551 ext'
<039> contactEmailAddress-EmailAddressofpersonidentifiedindataline<o3o> tami'shuonek@t-mobiLe com
TO BE COMPI-ETED BY THE REPORTING CARRIER, IF AN AGENT IS FILING ANNUAL REPORTS ON THE CARRIER.S BEHATF:
Certification of Officer to Authorize an Atent to File Annual Reports for CAF or Ll Recipients on Behalf of ReportinS Carrier
certlfythat(NamoofAgent)isauthorizedto3ubmltthelnfomatlonreportodonbehalfofthoreportlngmrrler
lso certfy that I am "n om"", ot$lIf,IIIlIlM[fE]Ii![Ii0e8 inctude ensuring fie accuracy of ths annuat data rcpo.ttng requlrements provldod to tho authorlzed
rgent; and, to the b€t of my knowledge, the reports and data provided to the authorlzed agent ls accurate.
\lame of Authorized Acent:
vame of ReDddihs carrier:
;isnature of Authorized Officer:Date:
)rinted name of Authorized officer:
fitle or Dosition of Authorized Officer:
feleohone number of Authorized Officer:
itudv Area Code of Reoortihs Carrier:FilinE Due Date for this form:
under Title 18 of the United States Code, 18 U.S.C. 6 1001.
TO BE COMPTETED BY THE AUTHORIZED AGENT:
Certification of ABent Authorized to File Annual Reports for CAF or Ll Recipients on Behalf of Reportint Carier
the data reponed herein based on data provided by the reporting carrier; and, to the best of my knowledge, the information reponed herein is accurat€.
Name of ReDortinc carrier:
Name of Authorized A(ent Firm:
Sienature of Authorized Aeent or EmDlovee of Arent:Date:
Name of Authorized Asent Emolovee:
fitle or Dosition ofAuthorized Acent or Emolovee ofApent
IeleDhone number of Authorized Agent or Emplovee of Agent:
studv Area Code of Reportinr Carrier:FilinI Due Date for this form:
18 0f the united states code, 18 u.s.c. s 1001.
PaEe 22
479015<01D StudyArea Code
A3au&ce Wirelaas USA IJ . P .<015> StudyArea Name
<02D ProgramYear 2022
<03D Contact Name - Percon USAC should contact regarding this data Tui Sbrcnek
4253835551 *t<035> Contact Telephone Number - Number of percon identlfied ln data line <030>
<039> Contact Email Address - Email Address of person identified in data line <030>tanl . rhrcneket -mblle , con
I certifo under penalty of perjury that no universal service support has been or will be used to purchase,
obtain, maintain, improve, modiff, or otherwise support any equipment or services produced or provided
by any company designated by the Federal Communications Commission as posing a national security
threat to the integrity of communications networks or the communications supply chain since the
effective date of the designations
Please Provide Waiver Document
Allowable File Type (pdf only)
Name of Attached Document Listing Required
lnformation
(8fl)) Operatlng Companies
Data Collectlon Form
<010> Study Area Code
FCC Form 481
OMB Conffol No. 306O
Decenrber 2020
4 7 9015
<015> Study Area Name Assurance wireless USA L.P
<020> Program Year 2022
<030> Contact Name - Person USAC should contact regarding this data Tami Shwonek
<035> ContactTelephoneNumber-Numberofpersonldentifiedindataline<030> 42s383sss1 exc
<039> Contact Email
<810> ReportingCarrier
- Email Address of identified in data line <030> tami . shwoDek@t-nobile . qom
Assurance wlreless USA, L.P
<811> Holding Company T-Mobile USA Inc
<812> OperatingCompany Assuraoce Wireless USA, L.P
sAc
17 9 014
199016
2190).3
259024
/Mem 249029
359014
5290r.3
5 3 9003
409025
459018
549016
4690r4
roin Mobile USA LP 139003
<813><a1>
Affillates
T-Northeast LLC and T-Mobile Central LLC
T-Mobile NortheasE LLC
T-Mobil-e South LLC
Powertel Inc. and T-Mobile Central LLC
Powertel-1S Inc. and T-Mobile South LLC
T-Mobile Central LLC
T-Mobile West LLC
T-Mobil-e Puerto Rico LLC
California LLC
Met
MetroPCS
Mass
MetroPCS Mi-chi Inc
MetroPCS Nevada LLC
Me P New York LLC
MetroP a
MetroPCS Tviin Mobile USA LP
Vi in Mobile USA LP
Vi in Mobile USA LP
Vi in Mobile USA LP
Vi 1n
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DBA T- Mobile
DBA T- Mobile
DBA T- Mobil-e
1
DBA T- Mobile
DBA T- Mobife
DBA T-ile
DBA T- Mobile
Metro T-Mobile
T-Mobi1
Metro T-Mobile
Metro T-Mobile
Metro T-Mobile
r T-Mobile
Assurance Wireless
Assurance Wireless
Assurance Wirel-ess
Assurance Wireless
W
LP
I
(8txll oeerating Companies
lData
Collection Form
FCC Form tl81
OMB Control No. 3060.
December 2020
<010> Study Area Code 479015
<015> Study Area Name Assurance Wireless USA L.P.
<020> Program Year 2022
<030> Contact Name - Person USAC should contact regarding this data Tami. Shwonek
<035> Contact Telephone Number - Number of person identified in data line <030> 42s383sss1 ext
<039> Contact Email Address - Email Address of person identified in data line <030> tami . shwonek@t-rcbife. com
<810> ReportingCarrier Assurance Wireless USA, L.P
<811> Holding Company T-Mobile USA Inc
<8I2> OperatingCompany Assurance wireless USA, L.P
<813>
Affiliates
in Mobile USA LP
Mobile USA LP
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in Mobil-e USA LP
in Mobife USA LP
in Mobile USA LP
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in Mobile USA LP
in MobiLe USA LP
in Mobile USA LP
Mobile USA LP
Mobile USA LP
Mobile USA LP
i1 LP
ile USA LP
i1e USA LP
Mobile LP
Mobile USA LP
Mobile USA LP
Mob le USA LP
v
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in Mobile USA LP 579003
56 9003
279012
229015
359126
349033
32 901r.
419024
26902'7
2'79034
119003
18 900 9
10 9 010
319023
369018
429025
289028
23901A
129005
169003
499015
5s9021
15 901 8
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Doing Business As Compan
Assurance reless
Assurance Wirel-ess
Assurance Wireless
Assurance Wireless
Assurance Wire]ess
Assurance Wirel-ess
Assurance Wireless
Assurance Wireless
Assurance Wireless
Assurance Wireless
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Assurance Wireless
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Assurance Wireless
ur Wi
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Assurance Wirel-ess
Assurance Wireless
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I(8ool
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Operating Companies
Collecion Form
FCC Form rt81
OMB Control No. 306O
December 2020
<010> Study Area Code 4?9015
<015> Study Area Name Assurance Wireless USA L.P
<020> Proqram Year 2022
<030> Contact Name - Person USAC should contact regarding this data Tami Shwonek
<035> Contact Telephone Number - Number of person identified in data line <030> 42s383ss51 ext
<039> Contact Email
<810> ReoortinsCarrier
Email Address of identifled in data line <030> tami . [e-mail]. con
Assurance }Jireless UsA, L.P
<811> Holding Company T-Mobi.Ie USA Inc
<872> OoeratinsComDanv Assurance wireless USA, L.P
<813><a1>
Affiliates
Mobile USA LP
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in Mobile USA LP
Mobile USA LP
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Mobile USA LP
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Vi 1n
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PRWireless PR LLC
Vi in Mobile USA LP
sac
30 9005
s39011
7'7 9072
589006
249073
299018
449067
509006
19 9 013
529074
339032
20901S
639007
209015
Doing Business As Compan
Assurance reless
Assurance Wireless
Assurance i,tli-reless
Assurance Wireless
Assurance Wirel-ess of t
Assurance Wireless
Assurance Wireless
Aa W
Assurance WireLess
Assurance Wireless
wi
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