Fillable Emergency Broadband Benefit Program Service Provider Election Form (Universal Service Administrative Company)

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Emergency Broadband Benefit Program Service Provider Election Form (Universal Service Administrative Company)

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Emergency Broadband Benefit Program
Service Provider Election Form
A
ll broadband providers (both eligible telecommunications carriers (ETCs) and non-ETCs) that wish to
participate in the Emergency Broadband Benefit (EBB) Program must file an election notice with USAC.
Providers should email this completed form and the following documents to EBBElection@usac.org
.
1. F
CC approval of your company’s participation in the EBB Program (required for non-ETC
s
a
nd ETCs that wish to participate in states outside their ETC designation)
2. ETC designation(s) (required for ETCs)
3. Service plan details on offerings for which the provider plans to seek EBB reimbursement (s
ee
Section D for more details)
4.
Evidence that the provider had the same service offerings available on December 1,
2020
(see Section D for more details)
If your election is missing required information or documentation
, processing may be delayed. All fields
on this form are required, unless noted as “if applicable.” The “if applicable” fields are required for
providers that are able to submit the information. Certain sections only apply to certain types of
providers.
S
ection A: Service Provider Information
Provider Type
ETC
☐
ETC with non-ETC affiliates ☐
Non-ETC ☐
Provider Name
DBA Name (if applicable)
Provider Address
FCC Registration Number (FRN)
DUNS Number
DUNS +4 (if applicable)
EIN (Federal Tax ID Number)
FCC approval number, if applicable
(e.g. EBBAxxxxxxx)
Service Provider ID Number (SPIN) (if applicable,
ETCs only)
Business Type
Holding Company (if applicable)
Provider Officer Name
Provider Officer Phone Number
Provider Officer Email Address
Provider Contact
Contact Address
Contact Phone Number
Contact Email Address
Preparer Name (if different from Provider Officer)
Preparer Company (if different from Provider Officer)
Preparer Phone Number (if different from Provider
Officer)
Preparer Email Address (if different from Provider
Officer)
Consumer Website URL
Consumer Support Phone Number
S
ection B: Approval to participate in the Emergency Broadband Benefit Program
If non-facilities based, list the underlying provider(s)
that provides your network facilities
Does your company plan to offer connected devices?
If yes, attach documentation detailing the
equipment, rates and applicable costs of each
laptop, desktop or tablet.
Yes ☐ No ☐
Does your company plan to connect to NLAD and/or
the National Verifier using an application
programming interface (API)? (Refer to Section F for
more information.)
Yes ☐ No ☐
S
ection C: For Non-ETCs ONLY
Does your company operate on Tribal lands?
Yes ☐ No ☐
Does your company offer pre-paid service?
Yes ☐ No ☐
Is your company’s service facilities based?
Yes
☐
No
☐
Section D: Service offerings
Please select each state/territory where your company will offer EBB Program service and identify the
service(s) available in the state/territory. Please review all documentation requirements
before
finalizing your election notice. Processing delays will occur if all requirements are not met.
At
tach documentation detailing each service offering for which your company plans to seek
reimbursement through the EBB Program that includes ALL of the following details:
• Speed and data caps,
• Standard rate for this offering, including indication that it is a monthly, recurring cost,
• Equipment costs,
• Jurisdiction where it is offered, and
• Documented proof establishing this offering was available on December 1, 2020.
Examples of service offering documentation include customer bills, price lists, website screenshots,
and advertisements. Evidence must clearly indicate current availability and availability on December
1, 2020. (The December 1, 2020 evidence can be dated as early as September 1, 2020.
Documentation dated earlier will not be accepted.)
These service plan details must be shown for every state selected below.
☐Alabama (AL) Fixed ☐ Mobile ☐
☐Alaska (AK) Fixed ☐ Mobile ☐
☐Arizona (AZ) Fixed ☐ Mobile ☐
☐Arkansas (AR) Fixed ☐ Mobile ☐
☐California (CA) Fixed ☐ Mobile ☐
☐Colorado (CO) Fixed ☐ Mobile ☐
☐Connecticut (CT) Fixed ☐ Mobile ☐
☐Delaware (DE) Fixed ☐ Mobile ☐
☐District of Columbia Fixed ☐ Mobile ☐
☐Florida (FL) Fixed ☐ Mobile ☐
☐Georgia (GA) Fixed ☐ Mobile ☐
☐Hawaii (HI) Fixed ☐ Mobile ☐
☐Idaho (ID) Fixed ☐ Mobile ☐
☐Illinois (IL) Fixed ☐ Mobile ☐
☐Indiana (IN) Fixed ☐ Mobile ☐
☐Iowa (IA) Fixed ☐ Mobile ☐
☐Kansas (KS) Fixed ☐ Mobile ☐
☐Kentucky (KY) Fixed ☐ Mobile ☐
☐Louisiana (LA) Fixed ☐ Mobile ☐
☐Maine (ME) Fixed ☐ Mobile ☐
☐Maryland (MD) Fixed ☐ Mobile ☐
☐Massachusetts (MA) Fixed ☐ Mobile ☐
☐Michigan (MI) Fixed ☐ Mobile ☐
☐Minnesota (MN) Fixed ☐ Mobile ☐
☐Mississippi (MS) Fixed ☐ Mobile ☐
☐Missouri (MO) Fixed ☐ Mobile ☐
☐Montana (MT) Fixed ☐ Mobile ☐
☐Nebraska (NE) Fixed ☐ Mobile ☐
☐Nevada (NV) Fixed ☐ Mobile ☐
☐New Hampshire Fixed ☐ Mobile ☐
☐New Jersey (NJ) Fixed ☐ Mobile ☐
☐New Mexico (NM) Fixed ☐ Mobile ☐
☐New York (NY) Fixed ☐ Mobile ☐
☐North Carolina (NC) Fixed ☐ Mobile ☐
☐North Dakota (ND) Fixed ☐ Mobile ☐
☐Ohio (OH) Fixed ☐ Mobile ☐
☐Oklahoma (OK) Fixed ☐ Mobile ☐
☐Oregon (OR) Fixed ☐ Mobile ☐
☐Pennsylvania (PA) Fixed ☐ Mobile ☐
☐Rhode Island (RI) Fixed ☐ Mobile ☐
☐South Carolina (SC) Fixed ☐ Mobile ☐
☐South Dakota (SD) Fixed ☐ Mobile ☐
☐Tennessee (TN) Fixed ☐ Mobile ☐
☐Texas (TX) Fixed ☐ Mobile ☐
☐Utah (UT) Fixed ☐ Mobile ☐
☐Vermont (VT) Fixed ☐ Mobile ☐
☐Virginia (VA) Fixed ☐ Mobile ☐
☐Washington (WA) Fixed ☐ Mobile ☐
☐West Virginia (WV) Fixed ☐ Mobile ☐
☐Wisconsin (WI) Fixed ☐ Mobile ☐
☐Wyoming (WY) Fixed ☐ Mobile ☐
☐American Samoa Fixed ☐ Mobile ☐
☐Guam (GU) Fixed ☐ Mobile ☐
☐N. Mariana Islands Fixed ☐ Mobile ☐
☐Puerto Rico (PR) Fixed ☐ Mobile ☐
☐Virgin Islands (VI) Fixed ☐ Mobile ☐
Section E: For ETCs with non-ETC affiliates ONLY
Please list your non-ETC affiliates (e.g., provider name, state, and service type (fixed/mobile)):
S
ection F: API Access to USAC Systems
If your company intends to utilize an Application Programming Interface (API) to access either the National
Verifier or the National Lifeline Accountability Database (NLAD) as such functionalities are made available for the
Emergency Broadband Benefit (EBB) Program, and you have not previously signed an Interconnection Security
Agreement (ISA) with USAC, please complete and sign the ISA and include it with your election notice for the EBB
Program. Returning the signed ISA will ensure that your company can, at a minimum, access the staging
environment to test the National Verifier and NLAD APIs as they exist for Lifeline (as needed) while USAC
completes necessary system development to put EBB Program workflows in place.
ET
Cs that already use APIs to access the National Verifier or NLAD do not need to sign another ISA at this time.
However, USAC may require ANY participating provider to execute a new or modified ISA or an addendum to an
existing ISA to utilize APIs to access EBB Program workflows in either pre-production (staging) or production
environments once those functionalities are available. You will be notified if additional action is necessary.
S
ection G: Certifications and Signature
I certify, under penalty of perjury, that:
I. I am an officer authorized to submit this election form on behalf of the participating provider;
II. The participating provider understands and will comply with all statutory and regulatory obligations
described within the FCC rules and orders, including the public interest conditions of offering
Emergency Broadband Benefit Program services throughout its designated service area and all terms
and conditions and other requirements applicable to using the National Verifier, National Lifeline
Accountability Database (NLAD), Representative Accountability Database (RAD), and other USAC
systems.
III. The submitted service offerings listed in Section D include the same terms and conditions as those
services offered on December 1, 2020, or if the offerings have increased in quality since December 1,
2020, that the standard rate remains the same as it was on December 1, 2020.
IV. Based on information known to me or provided to me by employees responsible for the data being
submitted, the data set forth in this election form has been examined and is true, accurate and
complete. I acknowledge that any false statement on this election form or on other documents
submitted by the participating provider can be punished by fine or forfeiture under the
Communications Act (47 U.S.C. § 502, 503 (b)), or fine or imprisonment under Title 18 of the United
States Code (18 U.S.C. § 1001), or lead to liability under the False Claims Act (31 U.S.C. §§ 3729 – 3733).
V. In addition to the foregoing, the participating provider is in compliance with the rules and orders
governing the Emergency Broadband Benefit Program, and I acknowledge that the participating
provider is subject to the Federal Communications Commission’s enforcement, fine, or forfeiture
authority under the Communications Act. Failure to be in compliance and remain in compliance with
the Emergency Broadband Benefit Program rules and orders may result in the denial of funding,
cancellation of funding commitments, and the recoupment of past disbursements. I acknowledge that
failure to comply with the rules and orders governing the Emergency Broadband Benefit Program could
result in civil or criminal prosecution by law enforcement authorities.
VI. I understand that providing materially false information in this submission will disqualify a provide
r
from participating in the Emergency Broadband Benefit Program.
VII. The election form is true, complete, and accurate, and the expenditures, disbursements and cash
receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award.
I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may
subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or
otherwise. (U.S. Code Title 18, Sections 1001, 286-287 and 1341 and Title 31, Sections 3729–3730 and
3801–3812).
By signing, I consent to the disclosure of the information included in this election form, including the company
contact information, with third parties administering the Emergency Broadband Benefit Program on behalf of
the FCC.
Signed:
Printed Name:
Date:
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Emergency Broadband Benefit Program Service Provider Election Form (Universal Service Administrative Company)

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Completed 23 May 2021

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