2008 PAYPHONE SERVICE PROVIDER
FEDERAL UNIVERSAL SERVICE FUND (FUSF) SURCHARGE/FEE WAIVER CERTIFICATION
Full Legal Name of Payphone Service Provider (PSP) claiming waiver PSP’s Filer 499 ID
PSP’s address, city, state and ZIP code
PSP submits this annual certification in support of its request for a waiver of the Federal Universal Fund Surcharge/Fee (FUSF Fee) (as described in AT&T’s applicable federal access service tariffs). PSP 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, PSP represents and certifies as follows:
1. The PSP hereby certifies under penalty of perjury that it is purchasing service for resale in the form of telecommunications or interconnected Voice over Internet Protocol (“VoIP”) service. The undersigned also certifies under penalty of perjury that it either contributes directly to the federal universal service support mechanisms, or that each entity to which it provides resold telecommunications is itself an FCC Form 499 worksheet filer and a direct contributor to the federal universal service support mechanisms.
2. PSP understands that Federal Universal Service Funds (FUSF) will not be collected by AT&T and PSP will be responsible for collecting any FUSF as may be legally due from its customers/members and remitting it to the required authorities. PSP also understands that if PSP uses or consumes any exempted communication service, the PSP will report and remit any FUSF due to the required authorities.
3. The PSP 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).
4. If any exemption claimed on this certificate is disallowed, PSP agrees to indemnify AT&T for any and all taxes, fees, surcharges, other charges, interest and penalties, including all legal and collection fees or any other costs that may be assessed by any authority or jurisdiction for which this exemption has been claimed by PSP.
5. The undersigned individual is authorized by PSP to make this certification on its behalf.
Signature of authorized PSP representative Printed name and title of authorized PSP representative Date signed
PSP’s representative telephone number PSP’s representative E-mail address
Check the appropriate provision section below and provide any additional information where required.
[ ] RESELLER OF COMMUNICATION SERVICES
PSP is a reseller and contributes directly to Universal Service support programs. For this purpose, the FCC has defined reseller as “a telecommunications service provider that: (1) incorporates purchased telecommunications services into its own offerings; and (2) can reasonably be expected to contribute to support universal service based on revenues from those offerings.”
or
[ ] NO LONGER ENTITLED TO EXEMPTION
PSP understands that in accordance with current regulations, when the basis for exemption as indicated on this certificate changes or ceases to exist as to make PSP subject to the exempted tax, fee or surcharge, thePSP agrees to notify AT&T in writing within 30 days by (1) completing a new certificate, (2) checking this provision and (3) submitting the new certificate to the PSP Service Center.
Effective change date:______Attach a list of ANIs that are no longer exempt from FUSF assessment by AT&T.
Please complete certificate and any necessary attachment and return to AT&T using one of the methods below:
U.S. MailFaxE-mail
AT&T
FUSF PSP Compliance Center
208 S. Akard Rm 3120.06
Dallas, TX 75202
PSPFUSF10408