2016 Annual Federal Universal Service Fund Charge/Fee
Waiver Certification
Customer Name: / ("CUSTOMER")(Full Legal Name)
Customer Address:
CUSTOMER submits this annual certification in support of its request for a waiver of the Federal Universal Service Fund Charge/Fee (FUSF Fee) [as described in the applicable federal accessservice tariffs or applicable state tariffs or Guidebooks (relating to EUCL charges, PIC change charges or other interstate charges associated with resale services)] or Universal Connectivity Charge and Administrative Expense Fee (UCC/AEF) [as described in the applicable AT&T Service Guide, AT&T Master Carrier Agreement, AT&T Wholesale Master Service Agreement, AT&T Wholesale Master ISP Agreement, AT&T Global Master Carrier Agreement, Global Services Agreement, Agreement, Terms and Conditions, Guidebooks, Wholesale Services Supplements or other contractual agreement] [the FUSF Fee and the UCC/AEF shall be jointly referred to below as the “FUSF FEE”], with respect to the services identified on Attachment(s) A and/or with respect to the services not identified on Attachment(s) B [if the “Directions”explicitly permit CUSTOMER to use Attachment(s) B to certify those purchases] (collectively, the “Exempt Services”). CUSTOMER is required to contribute to the federal universal service support mechanisms pursuant to Section 254 of the Communications Act of 1934, as amended, and the FCC’s rules. Therefore, CUSTOMER represents and certifies as follows:
1.CUSTOMER certifies under penalty of perjury that it is purchasing service(s) for resale, at least in part, and is incorporating the purchased services into its own offerings which are, at least in part, assessable U.S. telecommunications or interconnected Voice over Internet Protocol (“VoIP”) services. CUSTOMER also certifies under penalty of perjury that it either directly contributes or has a reasonable expectation that another entity in the downstream chain of resellers directly contributes to the federal universal service support mechanisms on the assessable portion of revenues from offerings that incorporate the purchased services.
2.Check EITHER box 2 (a) or box 2 (b):
a. CUSTOMER (or its affiliate(s) identified below) files a Telecommunications Reporting Worksheet (FCC Form 499-A) with the Universal Service Administrator annually (or more frequently as may be required by the FCC).
Legal name of entity that files Worksheet:Address
Filer 499 ID: / NOTE: if you have any trade name(s) associated with this Filer ID, list such trade name(s) as instructed following the signature block on page 4 of this Certification.
Name of contact person
Phone number of contact person
E-mail address of contact person
If the entity that files the Worksheet identified above is not CUSTOMER, CUSTOMER certifies that such entity is an Affiliate of CUSTOMER, and that the FCC Form 499 Worksheet filed by such entity reports the revenues derived from the resale, at least in part, of the AT&T services identified on Attachment(s) A to this Certification or the AT&T services not identified on Attachment(s) B to this Certification if the “Directions”explicitly permit CUSTOMER to use Attachment(s) B to certify those purchases. CUSTOMER also certifies that it directly contributes to the federal universal support mechanisms on the assessable portion of revenues from its offerings that incorporate the AT&T services identified on Attachment(s) A to this Certification or the AT&T services not identified on Attachment(s) B to this Certification if the “Directions”explicitly permit CUSTOMER to use Attachment(s) B to certify those purchases. All references to “CUSTOMER” in this Certification shall include the Affiliate(s) identified above.
b. CUSTOMER is not a direct contributor to the federal universal service support mechanisms but CUSTOMER has a reasonable expectation that another entity in the downstream chain of resellers directly contributes to the federal universal support mechanisms on the assessable portion of revenues from CUSTOMER’s offerings that incorporate the AT&T services identified on Attachment(s) A to this Certification or the AT&T services not identified on Attachment(s) B to this Certification if the “Directions”explicitly permit CUSTOMER to use Attachment(s) B to certify those purchases.
3. Check ONE of box 3 (a), box 3 (b) OR box 3 (c):
a. CUSTOMER identifies all services purchased from AT&T by CUSTOMER specified on Attachment(s) A to this Certification as for resale, at least in part, and CUSTOMER incorporates such purchases into its own offerings which are, at least in part, assessable U.S. telecommunications or interconnected VoIP services. CUSTOMER further certifies regarding contributions to the federal universal support mechanisms as specified in Section 2(a) or 2(b), above, and claims an exemption from the FUSF FEE with respect to the AT&T charges for all services listed on Attachment(s) A.
b. CUSTOMER identifies all services purchased by CUSTOMER which are notExempt Services and if the “Directions”explicitly permit CUSTOMER to use Attachment(s) B to certify those purchases, certifies that all purchases from the specified AT&T local exchange carrier other than those listed on Attachment(s) B are for resale, at least in part, and CUSTOMER incorporates all purchased services from the specified AT&T local exchange carrier other than those listed on Attachment(s) B into CUSTOMER’S own offerings which are, at least in part, U.S. telecommunications or interconnected VoIP services. CUSTOMER further certifies regarding contributions to the federal universal support mechanisms as specified in Section 2(a) or 2(b), above, and claims an exemption from the FUSF FEE with respect to AT&T charges for all services which the “Directions”explicitly permit CUSTOMER to certify using Attachment(s) Bother than those services listed on Attachment(s) B.
c. CUSTOMER is using Attachment(s) A to certify its purchases from AT&T companies other than local exchange carriers and Attachment(s) A or Attachment(s) B to certify its purchases from one or more AT&T local exchange carriers.
d.CUSTOMER understands that unless CUSTOMER previously certified for 2015 that (i) all services listed on Attachment(s) A to this 2016 Certification were Exempt Services and/or (ii) all services which the “Directions”explicitly permit CUSTOMER to certify using Attachment(s) B other than those listed on Attachment(s) B to this 2016 Certificationwere Exempt Services, CUSTOMER must provide such information at least thirty (30) days prior to the AT&T bill date on the invoice for which CUSTOMER seeks an exemption.
4. Check box below, if applicable:
CUSTOMER certifies that it is a reselling carrier and is using resold international switched service purchased from AT&T (identified on Attachment A) to refile the non-U.S.-billed traffic of itself or another non-U.S. telephone operator, and this traffic both originates and terminates outside of the United States.
5.If AT&T waives the FUSF FEE for CUSTOMER (in whole or in part) based on the information provided by CUSTOMER in this Certification, including all Attachment(s) A and / or Attachment(s) B to this Certification, and AT&T thereafter determines that inaccuracy in the information provided by CUSTOMER resulted in a waiver of the FUSF FEE with respect to charges that constitute AT&T end-user revenues (as defined by the FCC), then AT&T may bill CUSTOMER the amount of FUSF FEE that was waived as a result of such inaccuracy and, if AT&T does bill CUSTOMER this amount, CUSTOMER agrees to promptly pay such charges. If CUSTOMER is reclassified as an end user with respect to any Exempt Services, AT&T may bill CUSTOMER the amount of FUSF FEE that would have applied with respect to such services in the absence of the waiver plus any applicable late fees and/or interest and, if AT&T does bill CUSTOMER such amount, CUSTOMER agrees to promptly pay such charges. CUSTOMER further agrees to defend AT&T against any audits, claims, actions or lawsuits resulting from CUSTOMER’s Certification that it is exempt from paying the FUSF FEE and CUSTOMER further acknowledges its responsibility to promptly pay any resulting FUSF FEEs, damages, expenses, fines, judgments, interest, late fees, liabilities or losses resulting from such audits, claims, actions or lawsuits.
6.The FCC requires CUSTOMER to provide an updated version of its Certification to AT&T at least annually.
7.AT&T may provide a copy of this Certification and any Attachment(s) to this Certification to the Universal Service Administrator and/or the FCC. If AT&T does so, it will request confidential treatment of this Certification and any Attachment(s).
8.CUSTOMER is obligated to notify AT&T, either in writing or by other verifiable notification, and/or submit a new Certification with Attachment(s) to AT&T within thirty (30) calendar days of any change to CUSTOMER’s information or representations contained in this Certification, including any Attachment(s). CUSTOMER is liable for any applicable FUSF FEE, late fees and/or interest resulting from its failure to provide such timely updates to AT&T. CUSTOMER understands that CUSTOMER is responsible for submitting a service request to correct any difference(s) between any previously provided service request(s) or prior certification and any information contained in this Certification, including any Attachment(s).
9.The undersigned individual is authorized by CUSTOMER to make this Certification on its behalf.
(“CUSTOMER “)
By: ______
(Signature)
(Print or type name)
Title:
Phone:
E-mail:
Date:
Please list any trade name(s) associated with the Filer 499 ID set forth in the box on page 1 of this Certification on additional sheet(s); if additional sheet(s) are used, please check the box immediately following this sentence. □
Please return the completed 2016 Annual Federal Universal Service Fund Charge/Fee Waiver Certification form, together with all necessary completed Attachment(s) A [or Attachment(s) B, by February 26, 2016. Please follow the Directions(see Section A, paragraphs numbered 1 through 4, pages 1 and 2 of the Directions) for what to submit by e-mail addressed to. If you are unable to e-mail your completed 2016 Annual Federal Universal Service Fund Charge/Fee Waiver Certification form, together with all completed Attachment(s), follow General Directions, Section B, paragraphs numbered 1 through 3 (pages 2 and 15 of the Directions). Excel workbook templates for acceptable submissions by e-mail (5 tabs) and alternate method (28 tabs) are available on AT&T Prime Access [ and AT&T CLEC OnLine [
126 2016AT&T and CUSTOMER ConfidentialPage 1 of 4