20220728Assurance Wireless Form 481.pdf

PavisWightlremalne LLP
,i.:.:- ,, -; - ,-,, :1, i1: JI
Suite 2400
1300 SW Fnh Avenue
Poilland, OR 97201-5610
Heather f,oelter
50&.7/&3{06 tel
Re:
Heathermoelter@dwt. com
. !:1,'irl
July 28,2022
YU E-MAIL: seue taryt@puc. idaho. gov
Jan Noriyuki
Secretary
Idaho Public Utilities Commission
I l33l W. Chinden Boulevard, Bldg. 8
Suite 201-A
Boise,Idaho 83714
Docket GNR-t-22-01 - Assurance Wireless USA, L.P. - FCC Form 481
Certification Form
Dear Ms. Noriyuki:
Please find enclosed the FCC Form 481 of Assurance Wireless USA, L.P. ("Assurance") for filing
in Docket GNR-I-22-01. This supplements Assurance's Annual Lifeline Report, which was timely
filed on June 28, 2022. Please note that the Federal Communications Commission waived the July
1,2022 deadline for certification and submission of the FCC Form 481, and established a new
deadline of July 29,2022.1 The form was available on July 11,2022, and was timely certified in
the Universal Service Administrative Company's One Portal.
Please contact me at your convenience if you have any questions
Sincerely,
Davis Wright Tremaine LLP
Heather Moelter
HM/Kh
I l(ireline Competition Bureau Announces Availability of FCC Forn 481 Certification and July 29, 2022
Submission Deadline, Public Notice,DA22-743, WC Docket No. l0-90, 2022WL 2734367 (WCB 2022).
DWT.COM
Anchorage I Bellevue I Los Angeles I New York
Portland I San Francisco I Seattle I Washington, D.C
Page 1
<010> StudyAreaCode 4790L5
<015> StudyArea Name Aa6urencc nirele6B USA L-P-
<020> Procram Year 2023
<030> Contact Name: Person USAC should contact
with questions about this data Tanl shvon.k
<035> Contact
Number
Telephone Number:
ot the person identitied in data line <030>
,1253835551 exts
<039> contact Email Address:-rcblIe. conEmail of the pe6on
FormType s4.422
Page 1
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<03O> Cont.d l{ame - Plls usAC rhould @nt.d ..8ardin8 this dila
<03> contadT€lephoe Number - Number of paen idcntifi€d in data liae <o3o'253435s51'xt'
<039> Cont.dEmailAddr.$-Em.ilAddrcsorDcrsnidcnlificdindablinc<030> tlri.6h$ckot_rcbirc-coh
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<03(> Cont ct f{amc - Parson USAC should contact rctardint dtis dat
<035>Cont.ct Telephone Numb.r - Number of p€6on identmed ln data llnc
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<039> :ontect
EmailAddress- EmailAddresofperson idertificd in data llne t.d..M-dtl-d
<400>
<410>
<420>
s€lect from the dropdown list to indioate hoi, you would llke to rcpon
voicG complalnts (rero or treater) for voice telephony servlce ln the prlor
calendar year for each servica arca in which you are dcslgnatld an ETC for
any facllltirs you own, operate, leasc, or otherwitc utilize.
complaints per 1&)0 customers for flxed voice
Complalnts p€r 1(n0 customers for mobile voice
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<r:]D Contlct Nam - P.lM USAC rhqld cst ct @rdlmthis d.ta
<035> contrctTcbphoneNumbsr-NumberofErcnHantlflodtndatrllne<03o, 4,53135551 dE.
d39> Coht*l Emll Adde - EmllAddrcs of EMn ld.htllLd ln data llm d)3(b
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<12(> ProtnmYe 2023
ln dfi lhc dtot
d:l$ CoMtmillddr6-tmll
<90O, Do.s the flllng cntlty offGr trlbsl lrnd s.rvlc.s? (Y/il}
<910> Tribal lrnd(s) on whlch ETC Srms
<920> Trlbal Gdcmrcnt EngaSemant obllSatlon
It your @mplny sryGi Trlb.l hnds, pl..r shci (Y!r,No, NA) for !*h th6! bd.r
to @nflrm th. status d.$rlbGd on th..ttrch.d PDF, on lln.92O,
daM3tntc mrdin.tlon wlth tha Trlbal iq.rnmrnt pu6urrt to
5 54.313(.X5) includ6:
<921>Noods a$assmont atd doploymerd plannlng wilh a iocus on TIlbsl
cornrnunity andror lnsllhrtbm.
Fraslblllty and sustalnablllty plannln&
Markctlns $rulcc3 ln e culturally r.Bltlvr m.nnGt;
Compllencc wlth Rlahts of w.y pt@ss
Crmpll.ncr wlth trnd Us. pcrmtttlry ruquircm.nts
complianc. wlth F.cllltl3s sltint rulcs
Compllancc wlth Envlronmcntal Ravlcw pEcs*s
compllance wlth cultural Prusarvrtlon rovlcw procassas
Compllancc wlth Tribal Busin.sr 8nd Llc.nslnt r.quirrmrnts.
N.m of Afird.d Doarmnt
<922>
<923>
€24>
<925>
<925>
<927>
<928>
<929>
&loct
Y6orNotr
tlol ADplhable
I
Pegel
Pagc 8
<010> Study Arca Codc ru gors
<015> StudyArca Namc p.lr@e xlerc'. H !.p.
<020> Prognm Y.ar 2023
<030> ConEct Nam! - Plrson USAC ahould contact rrgardlrE thb data r.d sM*
<035> ContactTelcphmNumb.t-Numbcrof p.mnid.ntiflcdlnd.t llm<)3D {253835351 d.
<039> Contaet Em.ll AddEss - Emall Addrc3s of pcmn ldsntmcd ln data llnc <03O>
<1000>Vole srulccs rata comprnbility ertifietion
<101(>Attach dctelLd dascrlptlon for volc! srrukcs ntc
comp.rablllty compll.ncr
<1020 Broadband smp.r.blllty ccntfiation
<1030>Attach drtallcd dcscrlptlon for broadband
compaEbility cmpllencr
Name of Attachad Docun*nt
ttlam of Attechcd Dfiumnt
Pagc 8
Pagc 9
<O1O> StudvAr.e Cod.
<015> StudyArca N.m.&tr.e6 lir.L.. tr64 L.D-
Ycal
Contlct N!m! - Prmn USAC contact
<035> Contact Number -<03O> .25383s55r dr
<039> Contact Email Addrass - Email Addr.s of oerson id.ntmcd in drt lln. <)3O>
<1100> Ccrtify whrthrr t rrcstrial backhaul options .xlst (Y/N)
<U3O> Pleao select ths approprlate capoltss (Yes, No, Not Appliceblo) to connm tho
ropordng canlsr ofiers broadband sorvics of at leart I Mbps dowmtaam and 250 tbpg
upotraam wtthin th6 supporbd ar€a puBrrant to S 54.313(g).
<1140>Al8ka Pl.n rrt+of-rctum ertmetion (y!s, no, or not appllc.bbl of
compllancc srith apprdr€d pcrtomanc! plan.
Page 9
Pa8.10
<010> StudyAres Cod!a79015
<)15> studyAr., Nam!
<020> Proiram Yrar
<03D Cont ct Namc - PGmn USAC should contact rlr.rdim this d.ta
<03S> Contact T.bphon! Numb€r - Numbrr of prrson idrntlfird in drta linr <030> .r5!0355s1 dt.
<039> Contact Em|il Addla - Email Addr€ss of pcrson ldrntiflcd ln dat llne <030>
<1210> Tlrms & Conditions of Voice Telcphony Lifclinc Plans
<!220>
'Plo$ chck thm borc3 b.bw to 6nfrm th.t th. .tt ch.d dBumst(t), on lln. 1210,
or th! rcbalb llct d, on lln. 1220, @nElN th6 Equlnd lnfomtbn puEqnt to
5 54.422(.X2) .nnul EportlnS for ETCS EeMnt lfl-ln@m. suppor! €nl.E must
.nnqlly nport:
<t221> lnformtion describirg thc tcms and conditlons of .ny volc.
tclcphony $rvicc plans offerud to Liflline subscribcrs,
<122b D.tails on thc numbcr of minutes puidcd as part of thc plen,
<1223> Addition.l chartcs for toll calls, and Etcs for rach such plan,
Nam [rocumant
HTTP btlE://yw..sruuc.rtr.td!.en/Iq.1/r!ff-d-cdltid.
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Select the appropriate responses below (Yes, t{o, Not Applkablcl to note compllance as a rcclplcnt of frozen Hlgh Crst suppo6 Hlgh Coat support
to offset acccss charge rcducdons, and Conncct America Ptasc ll support as set forth ln 47 CFR 54.313(c),(d),(el. The lniormaton reported on tlrls
iorm and ln the documents attached bdry ls accurate.
<2015> 2015 and future Frozen Support Cenification 47 CFR t 5a.313(cXa)
Prlce Cap Carrler Connect Amerlca tCC Support {47 CfR S 54.313(dl}
<2016> Certificatlon support used to build broadband
Connect Amerlca Phase ll Reportlng {47 CrR 5 54.313(d}
<20L7A> Connect America Fund Phase ll recipient?
<2Ol7C> Total amount of Phase ll support, if any, the price cap carrier used for
capital expenditures in 2021.
<2018>Name of Attached Document Llstlng
Required lnformation
Connect Amerlca Phase ll - FCC Form 470 Postlnp
<2019> For the Illing due July 1 following full implementation of this requirement
answer yes, no, or not applicable to this ceftification request
P.a. 11
Attach the number, names, and addresses of communlty anchor
institutions to whlch the carier newv begian provldlnt access to
broadband service ln the preceding calendar year - 54.313(eXllfiifiA)
P.la U
<)10> StudyAreacode 479015
<015> StudyArea Name Assurance Wireless USA L.P
<)2D ProgramYear 2023
<030> Contact Name - PeBon USAC should contect regarding this date Tami Shwonek
<)35> ContactTelephone Number - Number of person identified in data line <030>4253835551 exU
<039> contactEmailAddress-EmailAddressof personidentifiedlndataline<o3D taml . shwonek@t-mobi1e. Com
(3oo7l Does this filing retain a Cost Consultant and/or Firm, or other Third Party to prepare flnanclal and
op€rations data disclosures submitted to the Natlonal Exchange Carrier Association (NECAI, USAq
or the Administrator?
Name of Consultant tame of f.onsultant Flrmfihlrd Psrty
P..! 1:I
P.a.13
<010> Study Area Code 47qO1 q
<015> StudyArca Naoe Aaarir.n.a wi ra'l aEa TICA T. D
<020> ProtEmYlar 2023
<O3O> Cont ct Name - Pctsn USAC should @ntact .lgarding this data Tami Shwonek
<035> Contact Telcphom Numb.r - Numbcr of peEon idcntifird lr d.t line <030> 4 2 5 3 8 3 5 5 51 ext
<039> ContacrEma[Md,.ss-EmaflAddresrofpeMntdenttfiedIndrt ltre<o3D Eami'shwonek@t-mobi1e'com
Select from the drop down menu or check the boxes below to note compliance with 54.313(fXU. Privetely held carriers must ensure compliance with the
financial reportint requirements set forth in 47 CFR 54,313(f)(2). I further certify that the information reported on this form and in the documents
attached below is accurate.
(300s)
(3010A)
(30108)
(3012A)
(3012B)
(3013)
(3014)
(301s)
(3015)
(3017)
(3018)
(30ls)
(3020)
(3021)
l3o22l
(30231
l3024l
(302s)
(30261
Progress Report on 5 Year Plan
canier certifirs to 54.313(0(1xiii)
Crrtifietion of Public lnt rcst Obligations {47 CFR !
s4.313(fxlxi}l
Plcae Pruidc Attachmrnt
Rrtcof-Rltum Communlty Attdlor lnslltutlon3
lndicatc ifthc cerri.r newly deployed broadband
pruicc to mmmunityrnchor institution(sl in th.
puious elcndar ycar.
Plea* Prwid€ Attachmnt
Using link, dmnload templatr and list the numbcr,
name and eddrc$ forcach community anchor
institution. Attach th. dcumcnt which conttlns th.
@mmunity anchor institution dctails as rcquiEd by
47 c.F.R. 0 s4.313(fl(1xiD
ls your @mpany. Privatrly Held ROR Gnier {47
cFR 5 s4.313(0(2ll
lf y.s, dcs yourcompany file thc RUS annual rcport
Plea* chock thcsc boxes to 6nfim that tlE
attachcd PDF, on llnc 3O1Z contains the Equir.d
information pu6uant to I 54.313{0(2} @mplian6
requires:
Elcctrcnic @py of tl€ir annual RUS rcports
(opcEting R"port for Tll!@mmunications
Eolwerl
Document(s)with Balamc shet, ln@rc stat mant
and Statcmcnt of Cesh Flffi
lf the r"sponsc is yes on line 3014 attach Your
@mpany's RUs annual rcport and all required
d€umentation
lfthc respons is no on |in.3014 ls your comp8ny
auditcd?
lf the rcspons it y6 on linr 3018, plc8$ chek thc
boxcs bllow to confirm yoursubmission on linc
:to26 pursuant to 5 54.313(0(21, contains:
Eithlr a copy ofth.iraudited financial rtetcm?nt; or
(2l a financial rcport in e format @mparabL to RUs
OpcntinS Rcport for Teleommuniatlons Borow€rs
Deumnt(s) for B.lane Shcct, lnomc Stat m.nt
and stat.mlnt of cesh Flrys
Manrgcmcnt lctt r and/or sudit opinion isucd by
thc indep.ndcnt c.rtificd public ac@untant that
performed the ompeny's financirl audit.
lf thc respons. is no on linc 301& plca* chlck tha
boxcs bclowto @nfirm yolr submision on linc
3026 pursuant to 5 54.313(0(2), ontains:
copy ofthcir financlal statcment which has bccn
subject to rcvicw by en independ€nt ertificd public
acountant; or 2l a financial rcport in a fomat
companble to RUs Opcnting Rcport for
Telc@mmuni@tions Eorcwers
Und.rlying information subjectcd to a rcvicw by an
independrnt certified public accountant
Underlying information subjecied to en offier
crtifletion.
Document(s) with Balsne Sh*t, lncom. Statemlnt
and statament of cash Flos
Attach thc workshcct listinE rcquir.d information
N.m. of Attachcd Docum.nt Listing Rcquircd
lnformation
Namc of Attachrd DGumrnt Listing
Rrquircd lnformation
(Yes/No)
(Ycs/Nol
l{smc of Attachcd Documcnt Listing Requircd
lnform.tlon
(Ycs/No) O O
oooo
Name of Attachcd Document Usting Rcquired
lnformstion
P.al 13
PaGe 14
HiurdrlDasmf,v
(3027) Rmnur
(3028) OpcEting Exprns3
(3029) Nrt lncoru
(30301 Telcphom Phnt ln ScrUGfrPE)
(30311Tot lAsti
(30321 Tot l Dcbt
(30331 Tot l Equlty
(3O:14! Dtuldcnds
P.ge !t
P.t 15
<01D StudyArea Code
<015>Area Name
<o30>Contact ltlame - Prrson USAC conttct deta
!q95> Contact Telephonc Number - Number of pcrson identited in data line <030>
<039>ContactEm.ilAddr6s-EmailAddrrssofparsonidentmedindataline<030> !.d..h'-&r-drr..cd
i!005 Rursl Broldbend E e€rlment
Authorized Rur.l Broadband Expcriment (RBEI recipi.nts must address the crrtiftcition fs public interest
obligauons and provide a list of newly served community snchor institutions.
Rrbllc lntercst Obllt3dms - FCC 1+98 (psraSraphs 2C29, 78)
Please address Une 4001 reSarding compliance with the Commission's public inter€st obligatlons. All RBE
partkipants must provide a respons! to Line 4001.
4001. Rdipient ccrtifiGs that it is ofrGring bmdbsnd me.ting the .cquisitr public interest obliSations consistcnt
with the cat.8ory for which thcy wcrc s.lected, lncludiru broadb.nd rp.c4 latcncy, ege capacity, and ratls that
are rrasonabv comparabb to ratcs for comparablc ofrerings in urban arca9.
RBE Communlty Andror lnsttutlons
<40o:la> lndicat. lf tho carrier newly deployed bro.dband s.flke to community .nchd institution(sl in the
prcvious calcndar ycar
<itd)3b> Plcase Providc Attachment: UsinS lint,
downlmd t.mplatr .nd list the numbcr, mme
and address for each community anchor
institution. A$ach thr document wlrich contains
th. community anchor institution d.tails ss
rcquircd by tCC 14-98 (paragraph 79)
Name ofAttachrd Documcnt Listit!8 Rcquircd lnformation
,I! l5
PI.16
<010>Study Area Codc
<015>Study&ea Name
<030>
<)39>
Contrct Name - Per$n USAC should ontact
Contad Email Address - Email Address of pemn
line <O3O>
<030) .u,.mat-drr..6in
5OO5 Alask. Plan
(5011)
(s012)
Please indicate whether any terrestrial backhaul or other satellite backhaul became
commercially available in the previous calendar year in areas previouslyserved
excluslvely by performance-limitint satellite backhaul.
lf the filing carrier identified in its approved perfomance plans that it relies exclusi\rely on
satellite backhaul for e certain poriton ofthe population in its service area, indlcate 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.
(Yes/No)
(Yes/No)
,ldhs.od t€hd ropbdon
(Yes/No)
Name of Attached
Document l"isting
Rcquired lnformation
<5013>
D.r..lftbn o, 8.ct}.ul tGhFb0
Alaska Plan Mobll. CrnlcrC Reasonably Compa.auG Rate t emonsbetbn
(5014a) Answer yes or no if moblle carriers receivlng support from the Alaska Plan can demonstrate
compliance at the end ofthe five.year milestone {2022} by showingthat your required stand-
alone voice plan, and one seMce plan that offers broadband data services, ifyou offer such
plant are:
o Substantially simllar to a service plan offered by at least one mobile wireless service
provider in the cellular market area (CMA) for Anchorage, Alaska, and. offered for the same or a lower rate than the matchint plan in the CMA for Anchorage.
Alaska Plan Moblle C.nlerC Reasonably Comparable Rat€ D€monstratlon Attachment
(5014b) lf ^Yes' is selected for 5014a, attach a document demonstrating compliance with the s-year
milestone. lf'No' is selected for 5014a, attach an explanation of non-compllance.
Ps 15
P{r 17
<01(>StudvArea Cod!
<r15>Arca Nsmc
<0lxr>contact Nam! - Pelson USAC should contact
<035>ContactTelcphonc Numbet - Numbcrof pcrson
data
<039>ContactEmailAddress-EmailAddrcssofpersonidentifirdlndataline<Xrc> td..h'.ft-dr1.."-
<6010> Enter the total amount of Phase ll Auction SuppoG if any, the carrier
used for capital expenditures.
Phase ll Auctlon and New York Funds Cortmcatlon
<6011>Certifu (either yes or no) .egading whether the recipient has awilable
funds for all proJect corts that wlll exceed the amount ofsupport that will
be received for the next calendar year. This certification must be provided
starting the flrst July 1st after receiving support until the recipien(s
penultimate year of support.
Phase ll Auctlon Communlty Anchor lnstltutlons
<6O12a> lndicate ifthr carrie. newly deployed broadband servlce to community
anchor institution(s) in the previous calendar year,
<6012b Please Provide Attachment Usint link, download template and list the
number, name and address for each community andtor institution.
Attach the document which contains the community anchor
institution detalls as requlred by FCC 1+98 (paragraph 79|.
(Yes/No)
Name of Attrchrd
Dcumcnt listing Requircd
lnlomation
Ph.se ll Arctlon FCC Form 470 PoctirEs
<5013> For the filint due July 1 following full implementation of this
requlrement answcr yes, no, or not applicable to this certlfication request.
Phrse ll Auctlon Post+lnal Deploym€nt Mll6tone Pcrionn m! C.rtmcadon
<6014> Slartint the ftrst July 1st after meeting the final service milestone, certifo
(yes, nq or not applicablel that the Phase ll-funded network that the Phase lt
auction recipient operated ln the prior year meets the.elevant performance
requirements ln s 54.309.
P.tc 17
P+1l
<010>StodyArea Code
<015>Area Name t.rc.. tl!.I..! E L.?-
202'
<030>Contact Name - Person USAC should contact data
<035>contact Telephonc Number - Number of pcrson idlntmed in data line <030>
<)39>contact Email Addrcss - Email Address ot pcrson idrrtificd in data line <o30>
<7010> Phase ll Auction recipient performance requirements certification (Yes/Nol
Ptr rl
PI.19
<OlO> qftrfu Ar.r arvl. .,.",.
kru.E. Ilr.f.r. m L,r.<r15> StudyArea Name<020> ProgEmYear<030> Contact Name - Person USAC should contact this data
<030>
Email Addrss - Email Address of perrcn identif,cd in data line <03D trd.rh@&t-dl1.."*
<035>
<039>
Contact
<8010>Unlendo a Puerto Rico State 2 Flxed - Capltal Ery€ndlturrs
Entcr the total amount of Unicndo a Puerto Rico Stage 2 fhed support, it any, the
orrier uscd for epital cxpenditurcs.
<801r.>Unlendo a Puerto Rico Stage 2 Fhed - Avallable Funds Certmcation
Ccrtify (cithlr yrs or no) regarding whcthcr th. r.cipient has available funds for all prcj.ct
costs that will cxcccd thc amount of support that will be reeivrd for th. next calcndar
year. This ccrtifietion must br provided starting thc firctJuly lst aftcr reciving support
until the rrcipirnt's penultimatr yrar of support.
<go12a> Uniando r Puerto Rlco State 2 Fircd - Communlty Anchor lnstltutions
lndietc if thc orricr newly deploycd bredband sruicc to community enchor institution(s)
in thr prcvious ebndaryear.
<8012b>
Plcase Providc Attachment
Using link, download template and list the numbcr, name and addrcss for each community
anchor institution. Attach the documcnt which contains the community anchor institution
details as rcquircd by 47 C.F.R. 0 54.313(e)(2XA). Allowablc File Typcs.
Unlendo a Puerto Rlco Statr 2 Flxed - FCC Form 470 Postln$
<E013> For the filin8 duc July 1 following full impl.mrntation ofthis rcquircmrnt answcr ycs, no, or
not applieblc to this ertifietion request.
<8014>
<8020>
<8030>
<8040>
<8050>
Nam. of Attach.d
Documcnt Listing Rcquircd
lnformation
Unlendo a Puerto Rlco State 2 Flxed - Post-Flnal D€ploymrnt Mllestona P€rlormance Certlflcatlon
Starting tha first July 1st aftar m.rting thc final scruice mileston!, crrtify (ycs or no) that the
Uniendo a Puerto Rico Stage 2-funded network that the Stagc 2 rcclpi.nt opcnted in the prior
year mets thr rclcvant performancc rcquiramcnts in I 54.309.
Uniendo a Puerto Rico State 2 Flxed - Support Relmburscment Certlflcatlon
54.313(n): R.cipients of Uniendo a Puerto Rlco Fund StaSe 2 fired support shall ccrtify that
such support wa3 not usd for costs that arr (or will bc) rcimbued by other sources of
suppoG includinS of fcdenl or lmlgocmmcnt aid or insuEncc rcimbuBemcnts; and that
support was not used for othar purposcs, such as thc rctir€mcnt of company dcbt unrclated
to lligible expcnditurcs, or othar axpens.s not diroctly relatrd to network rcstoration,
hardening, and expansion consistant with the framawork ofthr Unlando a Pulrto Rirc Fund.
Uniendo a Rrerto Rlco Stage 2 Fixed - Disaster Prcparcdncss and Response oodmentatlon
54.313(n): Reclplcnts of fixrd support from StaSc 2 ofthr Unicndo a Pucrto Rico Fund shall
certity that thly have conduct.d En annual review of the documcntation rcquircd by section
54.1515(a)-(c) to dltcrmine thc nced forand to lmplcmetrt changes or revisions to disstlr
preparation and racovery documentation.
Uniendo a Puerto Rico Statc 2 Mobile - Support Reimbu6ement
9.313(nl: R.cipicnts of Uni.ndo a Pucrto Ri@ Fund Stagc 2 mobilc support shall crtify that
such support was not u*d for 6sts that are (or will be) reimburccd by other surus of
support, including of fedcnl or lml govrrnmcnt aid or in3unncc rcimburcmcnts; and that
support was not used for othrr purposes, such as thc retirement of company dcbt unrclatcd
to cligiblc rxpcnditures, or othrr cxpcnscs not dircctly relatcd to nctwork rcstoration,
hardenin& and cxpansion @nsistrnt with thc framcwork of thc Unicndo a Puerto Rlco Fund.
Unlendo a Puerto Rico State 2 Mobile - Dlsaster Preparednesc and RespoNe Documentatlon
54.313(n): Recipi.nts of mobile suppon frcm Stagr 2 ofthe Unirndo a Pucrto Ri6 Fund shall
ccrtify that they have conductcd an annual rcview of the documcntation requircd by section
54.1515(a)-(cl to determine thc necd for and to implement changes or revisions to disastrr
prcpaGtion and rccov!ry dtrumantation
Unlendo a Puorto Rico St.te 2 Moblle - Moblle Disbursements Certlficatlon
54.313(o): Recipients of Unicndo a Puerto Rico Fund Stage 2 mobila support shall certity that they are in
compliencc with all rcquircmcnts for reccipt of such support to continuc receiving Stag. 2 mobil!
disbuEem.nts
<8060>
P.ge 19
PI! 20
.nln: (t'rlv Aim l^d.
<015> StudyArca Name b.*.oc rir.r... B !.D.
Year
<030>Contect Nam€ - Pemn USAC colttact
<035>ContactTclephone NumbGr - Number of person in data line <030><039> contact Email Address - Email Address of person ldentllied In d.ta line <030> rd.thd.h-d11..c6
<9010>
<9011>
<9012a>
<9012b>
<9013>
Connect USvl Statc 2 Flxed - Gpital Expendhur€s
Ent rth.totalamountofConncctUsVlFundstag.2fixedsupport,ifany,thcerricruscd
for 6pital Gxpcnditurcs.
Conn€ct USvl State 2 Flxcd -Avallabh Furds Certiflcatlon
certify (cithrr ycs or no) r.8.rding whcthcrthc recipicnt has availablc funds for ell pmject
costs that will rxeed thc amount of support that will be rcccived for the nrxt cal.nderyear.
This artifietion must b! providcd starting the fiBtJuly lst aftcr racciving support until the
rccipicnt's pcnultimata ycar of support.
Connect USVI Strge 2 Flxed - Communlty Anchor lnstltutlons
lndiete if th. carrier ncwly deployed broadband scruic. to community anchor institution(s)
in thc pravious alcndar yaar.
Plea$ Provid. Attachment
Using link, download tcmplat. .nd list thc numb.r, nama and addr.ss for cach community
anchor institution. Attach thc document whlch @ntains th. community anchor lnstltution
dctails as rcquircd by a7 c.F.R. 5 54.313(eN2Xi)(A).
Connect USVI St t€ 2 Fked - FCC Form 470 Postlrys
For the filing due July l followint full impl.mlntation of this requircmrnt anmr ycs, no, or
not applieblc to this certification raquast.
Connect Uslrl State 2 Flrcd - Post-Flnal Deployment Mll.slone Performance Certiftcetlon
starting thr lirst July lst aftrr mccting the final srryice milcstonc, ertify (yes or no) that the
Connect USVI Fund StaSr 2-fund!d network that th. state 2 r.ciplcnt opcratcd ln thc prior ycar
mlrts the relcvant pcrformance rcquiremcnts in I 54.309.
Conn€ct USVI Stetc 2 Flxed - Support RelmbuEement Certmation
54.313(n): R.cipicnts of Connrct USVI Fund StaSc 2 fixed support shall certify that such support was
not usd for costs that arr (or will be) rcimbuBrd by other surEs of support, including of fcderal
or lml govcmmcnt aid or insurancc rcimbummrnts; and that support was not us.d for othcr
purposs, such as the retirrmrnt of @mpany dabt unrclated to cligible expenditurct orothcr
cxpcnsls not dircstly clatcd to nltwork rastor.tion, hardcnin& and axpansion conslstent with thc
fmmework of the Connccl Usvl Fund.
Conn€ct USvl StaSe 2 Fixed - Diraster Prrpartdnese and R6ponse Documentetion
54.313(n): Rccipicnts offixcd support from Stag! 2 ofthe Connect USVI Fund shall crrtify thet th.y
have conductcd an annual raviaw of the deumrnt.tion requircd by sectlon 54.1515(8)-{cl to
dltcrmina th! ned for and to lmplcmcnt chanias or ravisions to disaster praparatlon and rccovcry
docum€ntation.
Connect Uslrl Fund stage 2 Moblle - Support RelmbuGcment Cenmc.tlon
54.313(n): Rccipicnts of conncct UsVl Fund Stagc 2 mobile support shall c.rtlfy that such support
was not used for costs that arc (or will be) rcimburscd by othcr sourcs of support, including of
fcdenl or lml gwcrnment eid or insunne rcimbursements; and that support was not usd for
othcr purposcs, such as thc rctircmcnt of company dcbt unrrlatrd to eligiblc rxpcnditurcs, or othrr
exp.n*s not dirrlctly relatcd to nrtwork rcstoretion, hardcning, and expansion consistcnt with tha
fnmcwork of the Conncct USVI Fund. Recipiants of mobilc suppon f.om Staga 2 of the Connect
USVI Fund shall certify that they have conductcd en annual rcvicw of the documcntetion r.quircd by
scction 54.1515(a)-{c} to dctcrminc the nr.d for .nd to implcm.nt chan8ls or r.visiom to di$st.r
prcpaEtion and r@very dcum.ntation.
Conn.ct USVI Fund Stage 2 Mobllc - Dlsaster Preparedn€ss.nd Responsc Documentatlon
54.313(n): Reipients of mobilc supportfrom Statc 2 of the Connect USVI Fund shall certify that
thcy havc onductld an annual rsiew of thc documentation roquircd by *ction 54.1515(a)-(c) to
dctermine tha ned for and to implement chantes or revisions to di$ster prcparation and respons€
dcum!ntation.
Connect USVI Fund State 2 Moblh - Mobllo Dlsbursemcnts C.rtmcailon
54.313(0): R.cipients of Connlct USVI Fund Strg. 2 mobil. support shall ertify th.tthey arr in
complianc with all requiraments for rcccipt of such support to continue rccaivlnS steg. 2 mobilc
disbuHm!nts.
Namc of Attachcd
Document Usting Rcquircd
lnformation
<9014>
<9020>
<9030>
<9040>
<9050>
<9060>
Page 20
P...21
<nln: qtr,{v Ar.: a.rl.
<015> Study Arra Nsme EE.*. rr!.r... 6 !.!.
<)20>
<030>
<035>
Yaar
Contect Name -
Contact
Contact
00ntact
<030>
Email Address of person id.ntified in data line <03O> r.d.t&@*.r-drr.."*
<10010>
<1fi)11>
<10O12a>
<10012b>
<10013>
<10014>
nDo;Ctplt l Expendltu.es
Starting thc flrst July 1st aft.r rccciving support until th. July ltt after thc rccipient's
support tem has cnd.d, rccipirnts of RuEl Digital Opportunity Fund support must submit
thr total amount of support, if any, thc recipi.nt uscd for epital .xpcnditures in the
prcvious cabndar y.ar. This is rcquircd by 47 C.F.R. 5 54.313(cl(2XiXB).
RDOF AYallablc Funds CGftmcation
Pleasc provldc a rcsponse (cith.r ycs or nol to this ccrtificstion rcquast for any rccipicnt of
Rural Digital Opportunity Fund support that thc rocipicnt has aki18blc funds for all prci.ct
@sts that will cxc.Gd thr rmount of support that will bc rrceivld forth. next @ludar
ycar. This ccrtific.tion must b. providcd startint the firstJuly lst aftcr rceiving support
until thr rccipicnt's pcnultimat. ycar of support, as r.quir.d by rrquir.d by47 CF.R. 5
s4.313(.X2Xii).
f,DOF Communlty Anchor lNtltutlons
Rccipicnts of Rural DiSital Opportunity Fund support must attsch a list containinS the
numb.r, nam.s, .nd addresscs ofcommunity anchor institutions to which thc eligibh
telccommunications carrirr newly brgan providing acrss to bro.dband scruice in thc
prcccding ehndsr ycar. This filin8 is rcquircd by 47 C.F.R. 5 5a.313(.X2XiXA).
Pleasa Prcvidr Attachment
Using link, downlmd tcmplatc and list thc numbcr, namc rnd addrcss for each communlty
anchor institution. Attech th. dcumsnt which contains th! community anchor institution
dctails as rcquired byaT c.F.R. 5 5a.313{GX2XiXA}.
N.mc of Attached
Documant Usting
Rcquircd lnfomation
RDOF FCC Form 470 PoctlnF
For thc filing du! July lst followint full implemcntation of this rcquircmcnt, plea* providc
a rcsponsc (cithcr ycs, nq or not applieblc) to this Gnifletion raqu.st. Recipicnts of Runl
Oigital Opportunity Fund must rlspond affirmativcly th.t thcy bid on etcgory one
tclccommuniEtlons and lntcrnct accc$ srryices in rasponsc to all FCC Form 470 postings
secking broadband scrvicc that meets thr connlctivity tariats for th! schmls and llbrarics
univeml s.rvlca support protnm for eligibl! schools .nd libnrics (as dcscribed in 5
54.501) locatcd within eny ar€a in a census block whcre thc csni.r is rccciving Rural Di8ital
Opportunity Fund, and that such bids w.rc at rat.s rcasonablc comparable to ates chaEld
to cligiblc *hmls and libraries in urban aroas for lnstructions for Complcting Fcc Form .l81
OMB @ntrol No. 3060{986 (High{on)oMB contrcl No. 306GO819 (Low-lncomc}
Novembcr 2020 Page 44 compamble offcrings. This filing is rcquir.d by 47 C.F.R. I
5a.313(a)(210(c). This clrtifietion will not bc rcquirod until thc July kt following the E-
Ratc prcgnm ycarthat this obligation has bccn fully implcm.nted. Modrmizing thr E-Ratc
Prog6m for Schmls and UbErics.t al., Wc Dockrt. Nos. 13-184, 10-90, 29 rcc Rcd 15538,
15555-67, p8ra. 72 (2014).
RDOF PoEt-Flnrl DlDloymant Mll6ton. Prrformrnc. Ccrtmc.tlon
Starting th. flrst July lst after a Rural DiSital opportunity Fund rccipient meets its final
scryicc mil$tonc untll thc July 1st aft.r thc suppon racipirnt's support tcrm has cndcd,
plea* providc a rcsponsc (either ycs, no, or not applieblcl thet thc Ruml Digital
Opportunity Fund-funded network that thc support rsipicnt opcBt.d in the prior ycar
mcets tha rclcvant pcrformane rcquiremcnts ln 47 CF.R. I 94.3(D. This filing is rcquired by
a7 c.F.R. I sa.313(cx2r(iii).
Page 21
Pagc22
<01O> StudyArra Cod.{ 79015
<01S> studyArca Nam.Aasrance nLrelesa tSA L.P
<O20> Prc$amYrar 2021
<03(> Contact Nam. - PGrson USAC should ontact rerardinr this data Ta01 Sbuonck
<035> ContactTalaphoncNumbar-NumberofpcMnidantificdindrtallnc<030> 42s383sss1 exs
<039> Contact Email Addrcas - Emeil Addrr$ of per$n identifi.d in data line <030> taml . shwonek@E-nob1le. com
TO BE COMPTETED BY THE REPORNI{G CARRIER, IF THE REPORTING CARRIER IS FTLII{G ANNUAL REPORTII{G ON ITS OWN BEHALF:
Ce'tmcatlon of Offloer ai to the Accuracy of the Dat Reported for the Annual Reportlng for CAF or Ll Reclphnts
.sUfI th.t I am .n ofnc.r of tt rcportln! carlcr; my ruspondHlltlcs lndudc arrurlng tha acanrrcy ol the ennuel rcporont rcqulr.mcntr ior unhrcGal 3.rylc. suppott
Gdpllnts; .n4 to thc bcst ol mf tnodct:, thr lnfofmrtlon Gportrd on thb iorm and ln .ny rtt drmcnB b &runtr.
lame of Rcmrtinr Carirr. ABerance Wlrelesa IrSA I,. P.
iisnaturcofAuthorizadofficcr: CERTTPTED omrM Datr o7 /L5/2022
,rlnt.d name of Authorizcd offlccr: Larry welana
nth or msition of Authorized officcr: vlce PreaLalent
Ialeohone number of Autho.iz.d Officer: 9137 94 lil 52 ett.
;tudvA@ code of Remrtim c:riGr: '!?9015 Filin. Du. Drt. forthle l6n 0a / 07 / 2022
Pemnr willfully mklnt fal$ st t mnts on this fom en bc punishad by lin. orbit!]tun underth. communicatlonr AEt ot 1934 47 U,S.C !5 502, 508(b], orina d lmprignmnt
undcr frd. lE of thr Unit d St!t$ Codc, 18 U.S.C. 5 1001.
Page 22
P.ge 23
<01O> StudvArer C6d.4790t5
<015>Ar.a Naru Assurance sl.releaa USA t.P
<O2O> P.dhm Yrar 2023
<O3l)> contrct N.m. - PcMn USAC lhould contect rdrrdim thls drtt sbuonek
<035>a6fidT.l.hh^n.Numbcr NImh.? 6f D?rdn identm.dindrt llnc<o3o> 42s383ss51 ext
<039> Cnht d F6.il Addn3s _ Em.ll AddEs of mr3on identifi.d in d.b ltm <O!lO> Caml . Bhuonelt@C-rcblle . con
TO BE COMPTETED BY IHE REPORTING CARRIER, IF AI{ AGE]IIT IS FITIIIG AilNUAL REPORTS ON THE CARRIER'S BEHATF:
TO BE COMPI."ETED BY THE AUTHORIZED AGENT:
Certlflc.tlon of Otfker to AuthorLc an At nt to Flh Annu.l Rcpolts for CAF or Ll Rcclplcnts on 8lhalf of Reportlnt CatTlcr
b tutho.d to 3uhr{t tha ldornrton npord m b.hdt ot lh. npodng erds. I
rbo rrtly lhlt I sm m c,filor ot tha lrfodng errl.c my Bpo.r.luli0c lnciudr .mdng tl. rcaurrcy of lh. .nnul alrtr nDodng Equhmanta proyld.d io tha aulhahdlo nq !nd, b tr b.at o, nry knowladgf, lh. npofl3 8nd drt provldad to lha .utlstr.d agant b .eunt .
{rm. of Authori:cd Aa.nt:
{ama of Rcrcrtim cafflcr:
iimrtur. of Authorizcd Omccr:Drte:
,rlnt d rm of Authorlzcd Offlc.r:
ftL or positim of Authorlzcd Off,er:
Ichohom numbcr of Authorlzcd Offtcar:
itudv AH Codc of R.mrtlm C!ni!r:tiliil Drc Dltc forthis fom:
Pelur wiltfulh mkint f.l! *atrmnts on thb fom @n b. punlshld bV finc or torf.nuc undri the Communic.tion! AGt ot 19:t l, 47 U.S.C 5q 50e 56(b), or fin. or lmprbonrcnt
undlr Tlth 13 of thc Unttrd St trs Codc, 1t U.s.c I 1001.
Certflcatlon of Agent Authorized to Flle Annull Reports for CAF or U RGclplrnts on B.half of Reportlng C.rrhr
hcd.t nDortodhq*rb.rcdoddat ptorddcdbytficr.Dottftc.nhqerd,tott b.rtdmyfnoutledg.,tlxhmrtlonnportcdh.rlhb*dr.t.
Namc o, Rcrcrtim Carlcr:
N!ru of Authorir.d As.nt Firm:
lEmturc of Authorlz.d Aacnt or Employ!! of A8.nt:Dat!:
Iftl. or Dosluon of AuthorlzGd Asnt or Emdowc of Aaent
f.bphorc numb.r of Authorizad AErnt or Employ.. of Arent:
Study Arra Code of Reportlm Carrler:FlllrE Duc D8t for this fom:
Pag.23
Pra.24
<01D StudyAEacods
<015> SttdyArca N.m€
<020> Program Year
<03D contsct Nam! - Person USAC should contad reg.rdin! thls data
<035> Contact Tcbphonc Number - t{umber of pepn ldcntflcd ln d.ta llrc <030>
<r39> Contact €m.ll AddrGsr - Emell Address of peron ldentfhd ln d.ta llrc <030>ud.d@dE-dtt..co
I clrtify undcr pcnslty of pcrjury that no univcHl srvic! support hrs bcan or will bc u*d to purchasg
obtain, maintain, improvc, modify, or othcruisc support any cquipmcnt or saryiccs produccd or providld
by any ompany dcsitnatcd by thc Fcdlral Communicatlons Commission as posing a national slcurlty
thGat to the intcgrity of communicetions nctrcrks or the communications supply chain sine thc
effective date of the dlsignations.
Nam. of Attechcd Documcnt Listing RcquiEd
Yeg
Plca* Prwidc Waiv.r Documrnt
Allomblc File Typc (pdf onlyl
Plcas P0id. Waivrr Deumrnt
Allowable Filc Typc (pdf only)
I ertifythat no F.dcral subsidy madc av.ilablc thmuth a program edministrrcd by the commission that
provides funds to bc u*d for th! epital rxpenditurcs neccssary forthc provision of advanccd
communications scruiccs has bcen or will bc u*d to purchasc, rcntr laasc, or othcrwis obtain, any
covcred ommunietlons cqulpm.nt or sNlc€, or maintain €ny covered ommunl@tionsequlpmrnt or
seruice prwiously purdrasd, rcntcd, lasd, or otheili* obtain.d, rs rcquirrd by 47 C.F.R. I 54.10.
lnformation
N.rc of AttaclEd Dodment Listing Rcquircd
lnfomation
Yeg
PaE 24
<01D StudyArc.Code
<015> StudYAE il.m k.nr h.. xt..1.t, ter L-P-
<)2O, ProiEm Y6r 2023
<,3{> Cont ct Nam - Pemn UsAclhould cmt ct mrdimttls d.t!
<O35> Contact TClCphonc ilumbar. Numberof FMn Hentifled ln drta llne <036 a2s3.!5551 ut
<)3!r> Cont*t Emll AddB - Emll Mdrr$ of pcmn ld€ntlfEd ln d.tr llN <)3(>
41(> fi€mrtlm c.nhr &!u.Dcc ilFls. @, !.P.
411> Holdlm cohEnv l-611. gEA ltrc.
<El2> Op.Etlnrcampany M.uruca r1r.1... ssA, Ll.
<813>
rrmhcr
T
usA
DoltI Budnars &Coi[fiyor tmd Dcdtnlbnsc
17901{DBA T- n4obi:
1e lilortheaat LLC 19t016
219013
l/MemDhia, Inc. ild T-Mobi"Ie CentraL LLC 2eao2a'!.{emDhis. Inc. and T-Mobile South LLC 389029
369ota
5U t0t3
63t003
Metro bv T-Mob
Metro bv f-Mob'1vmia. LLC Metro bv T-Mob
Metro bv T-Mobl
259072 AsEurance W
409025 ABgurance wire
{59018rbile usA LP 549015 Aasurmce $ir,
bile UsA LP {6901a AdEurance W
]biIE I'SA LP 1!900t AEetrranca Wira
AaEurance
<}10t Study AEa Code a79015
<ll5> StudyAE tlam rluac. tir.I... u& !.P-
<)2O> PuEmYear 2023
<)3(> Cont*t il.re - PG'w USAC rhaH @ot ct r€r.rdlEthB dat
<)35> Cont .t TcbDhooe ilumbc. - ilumb.r of Dqu ld.itirled h datr llE d:lo> .25!!35551 dt
<)3$ Cont ct Emll Addrs - EmllAdd6 of Em ltGntiH ln dat Irc <)3(>
€l0> ReDortimCarder &.unnc. xlrclca. gga, L.P.
<811> HoHIEClmoanv T"rcb1l. UaA Iac
<81D Oprratlnr Cmpanv E.urMc! ilr.1car !S, I.P
413>
tfilLtc3
uobile USA LP
sc
n Mobile USA LP 579003
55900i ABdurance W
21tO12 AEaurance W
229015
359126
.n ti{obi1e USA LP t49033
n Mobile USA LP !29011
419024
259021 A88urance !I
219011
119001
10t010
31902f AErurance tI
369014
12902B
-tli]a USA LP 129005 AEaurance !f
vlabi Ie IISA f,D 15900t
,bile USA LP
n Mobile USA LP
^hilA IrCl T,D
Doftl ArdnclEAs ConUmVor lnnd Dc{nrdon
Bg
A6gurance
<r10> StudyArcacodr ar90tr5
<)20> P@ah Ydr
<):rD Contact Nare - Pels USAC stwH @rt ct mrdlmtib data
C.ild T.b6h. trlhbr - Xrhbr d EM il.df,d L 14. lih. dtd arB!a!5551 *ts
<r39> C.nt d Emil AddlB - Emll AddEs of Een ldrdiLd in dd llm <}:il> r.d.&mGbt-bbui.c6
dlOt Eedcc lllclG.a B, !.P.
g^Hlma^heN
<8I> ODeEtimcrmDony E.ree tir.I... EA, !.P.
<813>
ffmh6 Doh! admrt Ar Goltielty or ann l D.*mdoi
Assurance l{lrelesgUSA I,P
USA IIP
USA LP
sac
rOlN MO-bAIE IISA LP 309005 Aadurance
roin Moblle IISA l,P 17941'
2a00tl
?99018
aa9051
509005 AaEurmce W
199013
5290ra
1e USA LP !!9032
1e USA LP 200o15
209015
53900?
AFFIDAVIT OF BUSINESS OB CORPORATE OFFICER
The ldaho PuHic Ulilities Commissim Order No. 29841 requires lhat Eli$He Telecommunications
Caniers (ETC) cBnily that it is cornpliant with applicable seruice quality slandards and consumer
prolection rules; and ETGs mustdemonetate the abllity lo remain lunctimalin emergencies. ln addilion,
the Corrrnlsslon must flle an annualceiliflcatbn u,ith tho USAC and the FCC that all federal hph-cost
support provided to ETGs within the Strate ol ldaho wil! be used only for the prwision, maintenancs, and
upgrading ol facilities and seMces forwhich the eupporl is intended. Accordingly, the undersigned states
and vedlies undcroath the following:
1, lamanoflicerof Assunanoe Winless USA. LP-an elplble telecommunlcations
canier lor recetving lederal universal service support urder seclion 214(e) ol the
Telecommunicaliom Act of 1996 ln the state of ldaho.
2. l.UA
3.Assuranm Wirabss US,A^ L-P-ls complying with applicable serviee qualtty
standads and consumer prctecton rulcs o[ lhe Federal Gommunlcations Gommbsion and
the ldaho Publlc Utilill€s Commisdoil
4. I ccilifr to th€ Cdnmission that the Company ls able to remain furrclional h emergendes
as set forth in Cornmbsbn Oder No.29841 and ln 47 C.F.R. S 54.202(aX2).
5. N/A
6. THs verifbatlm and aflidavlt ls provlded to be the ldaho Public Utilities @mn$ssbn to
enable lhe IPUC to certifi to the FGC that lederal unlveral service suppon recelved by the
eligible caniers in lhe state will be used in a manner consistent wtth Section 254(e) of the
Tslecommunicalione Act.
Lrrr Wclanr. VIcr Prcrldent
StatE ol Kansas )
)ss
County ol Johnson I
SUBSCRIBEDAND SWOBN tothis 23vd dayof
belore mefitn-2 )O2 Z
Notary
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My Gommission
GEHTIFICATION BY ELIG IBLE TELECOIIIMUN ICATIONS CARRIER
OF COMPLIANCE WITH SERVICE OUAL]TY AND CUSTOMER
PROTECTION, ABILITYTO REMAIN FUNCTIO]\IAL IN EMEBGENCIES,
AI{D USE OF FEDERAL HIGH€OST SUPPORT.
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