Jurisdictional Traffic Certification Form

 

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Windstream currently provides private line or similar type services to your company. Universal Service Administrative Company (USAC) requires that carriers identify private-line or similar type services as state or interstate based on the jurisdiction of the usage1.

Please complete the online form below to identify the jurisdiction of the private line or similar type services that you have with Windstream.

If customer does not provide accurate or timely information to the Company, customer may be responsible for payment of the FUSF Surcharge.

If you have questions, please view our Q & A or email us at WINDSTREAM.Exemption@windstream.com with the subject line Jurisdictional Traffic Form.





Business Information:

Customer Legal Name*
Customer Address*
City*
State*
Zip Code*
Contact Person*
Contact’s Telephone Number*
Contact’s Email Address*
Account Number*

(If your company has multiple accounts and this submission applies to all your company accounts with all Windstream entities, please state “ALL”; otherwise, submit a form for each account number.)
Assigned PL#*

(from top right corner of Jurisdictional Form received)


Private Line Interstate Traffic Certification:

Customer represents and verifies as follows:

1. The amount of traffic routed over leased private line circuit(s) listed below represents:
State (Intrastate) Services – All services NOT more than ten percent (10%) Interstate of the total traffic on the service.Interstate Services – All services MORE THAN ten percent (10%) Interstate of the total traffic on the service.Mixture of circuits that is state or interstate.
If your circuits are mixed, please email Attachment A to WINDSTREAM.Exemption@windstream.com and list whether they are state or interstate.
2. Customer acknowledges that the Company may in its sole discretion provide a copy of this certification to the Universal Service Administrator, the FCC, or an authorized auditor.
3. Customer acknowledges that the Company’s determination of applicability of federal USF will be based upon the information provided by Customer in this Certification. In the event the Company exempts Customer from the payment of these USF related charges (in whole or in part) based upon the information, representations and certifications contained in this Certification, and the Company thereafter determines that Customer provided false, inaccurate, or erroneous information, then the Company may bill Customer, and Customer will pay, the federal USF related charges that were not billed, plus applicable late fees. Accordingly, if Customer does not provide accurate or timely information to the Company, Customer may be responsible for payment of the Federal Universal Service Surcharge. Furthermore, Customer agrees to indemnify and hold harmless the Company from any and all claims arising from any breaches of the information, representations or certifications made hereunder.
4. If, at any time, the Customer’s information, representations or certifications made hereunder are no longer accurate, Customer will notify the Company within thirty (30) calendar days by completing and submitting a new Certification Form to the Company.
5. The individual named below is duly authorized by Customer to make the representation and certifications contained herein on behalf of Customer.

Certification Signature:

I certify under penalty of perjury that the representations above are true and accurate.

Customer*
Signature*
Title*
Name*
*Required fields

1 FCC Form 499A instructions state “If over ten percent of the traffic carried over a private or WATS line is interstate, then the revenues and costs generated by the entire line are classified as interstate (36.154(a))