Skip Navigation

Federal Communications Commission

English Display Options

Commission Document

FCC Form 560 & Instructions

Download Options

Released: August 5, 2014
image01-00.jpg792x612

Approved by OMB

3060-0819

FCC Form 560

November 2012

LOW INCOME BROADBAND PILOT PROGRAM REPORTING FORM

PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS

The FCC is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. If we believe

there may be a violation or a potential violation of a FCC statute, regulation, rule or order, your certification may be referred to the Federal, state

or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order. In certain cases, the

information in your certification may be disclosed to the Department of Justice or a court or adjudicative body when a) the FCC; or b) any

employee of the FCC; or c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding.

We have estimated that this collection of information will take .5 hours. Our estimate includes the time to read the instructions, look through

existing records, gather and maintain required data, and actually complete and review the form or response. If you have any comments on this

estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission,

Office of Managing Director, AMD-PERM, Washington, DC 20554, Paperwork Reduction Act Project (3060-0819). We will also accept your

PRA comments if you send an e-mail to PRA@fcc.gov.

Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. You are not required to respond to a collection of information sponsored

by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control

number and/or we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-0819.

THIS NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. SECTION

552a(e)(3) AND THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION

3507.

12

image02-00.jpg792x612

COMPANY INFORMATION PROVIDED BY ETC WITH EACH SUBMISSION TO USAC

BLOCK A

Each ETC is required to submit the company specific information contained in block "Identifying Information - Block A" for each submission

to USAC. All raw data that the ETC submits may be submitted as an Excel or CSV file.

Block A

Question

Response

Notes

Service Provider Identification

Number (SPIN)

Study Area Code(s) (SAC)

FCC Registration Number (FRN)

Legal Company Name and d/b/a

Company Mailing Address

Company Telephone Number

Company Fax number

Company Contact Email Address

Reporting Date

Company Contact Name

Each variation of a proposed broadband service

offering that an ETC offers in its project will be

assigned a separate project code identifier by

USAC (Project Code Identifier).

List of Project Code Identifiers in Pilot

Project

13

image03-00.jpg792x612

PROJECT-LEVEL INFORMATION PROVIDED BY ETC

BLOCK B

Each ETC is required to submit information contained in block "Broadband Service Offering Information - Block B" to USAC once, at the beginning of

the ETC's project for each Project Code Identifier.

Block B

Question

Response

Notes

Project Code Identifier

Identifies the study group in terms of discount plans

List of geographic areas (e.g., census

tract, wire center, study area) receiving

this variation of the broadband service

offering

Identifies relevant geographies being treated in

study

Zip Codes receiving this variation of

broadband service offering

List all zip codes fully or partially in this variation of

broadband offering

14

image04-00.jpg792x612

PROJECT-LEVEL INFORMATION PROVIDED BY ETC

BLOCK C

Each ETC is required to submit information contained in block "Project Information - Block C," to USAC once, at the beginning of the ETC's project for each

Project Code Identifier.

Block C

Question

Response

Notes

Maximum number of months discount is

available

0 - 12

Number of months discount is offered in study

Type of service offering

Bundled Voice & BB; Stand-

alone BB

Technology used

Mobile, Fixed-wireless, Wireline

(Telco or Cable), Other (indicate)

Broadband speed provided

specify upload and download

speed

Provide advertised speeds.

Monthly usage limit, if any

GB/month

If usage limits do not apply, respond with N/A.

If monthly usage limit applies, whether overage

charges apply and if so, specify rate amount

If usage limits do not apply, respond with N/A. If

overage charges do not apply, respond with N/A

$

If monthly usage limit applies with no overage

charges, specify whether service is discontinued

or broadband speed is reduced

Discontinued service, broadband

speed is reduced, none of the

above (specify)

If usage limits do not apply, respond with N/A. If

overage charges apply for exceeding usage limits,

respond with N/A.

Monthly broadband discount amount

$

Monthly cost to subscriber for broadband service

after discount

$

Amount of discount provided to reduce or

eliminate non-recurring fee(s), if any

$

Amount of non-recurring fees, if any, charged to

subscriber after discount

$

Amount of discount for equipment provided to

subscriber by ETC, if any

$

If subscriber receives equipment at no cost, please

include value of equipment given to subscriber

Cost to subscriber of equipment provided by

ETC that is used for broadband after discount

$

Digital literacy training offered as part of

broadband service offering

Yes/No

15

image05-00.jpg792x612

PROJECT-LEVEL INFORMATION PROVIDED BY ETC

BLOCK D

Each ETC is required to submit information contained in block "Aggregate Population Information for Variations of Broadband Service Offering - Block

D" to USAC on a quarterly basis for each Project Code Identifier. If necessary provide a best estimate.

Block D

Question

Response

Notes

Project Code Identifier

Identifies the study group in terms of discount plans

Total number of Lifeline eligible

subscribers in study population

Estimate if necessary, explaining your assumptions

Total number of eligible subscribers

offered this variation of broadband

service during the pilot

Estimate if necessary, explaining your assumptions

Total number of subscribers enrolled in

the offered discount during the first

month of the quarter

Total number of subscribers enrolled in

the discount during the second month of

the quarter

Total number of subscribers enrolled in

the offered discount during the third

month of the quarter

Total number of subscribers that have

de-enrolled in the offered discount during

the first month of the quarter

Total number of subscribers that have

de-enrolled in the offered discount during

the second month of the quarter

Total number of subscribers that have

de-enrolled in the offered discount during

third month of the quarter

16

image06-00.jpg792x612

SUBSCRIBER-LEVEL INFORMATION PROVIDED BY ETC

BLOCK E

Each ETC is required to submit the information contained in block "Enrollment Information - Block E" to USAC when all subscribers have

enrolled in the ETC's project. Each subscriber must have a unique identifier, which will be used throughout the study, assigned by the ETC

(Unique Subscriber Identifier).

Block E

Question

Response

Notes

Unique Subscriber Identifier

Unique, anonymized identifier assigned by ETC

Project Code Identifier

Identifies the subscriber's study group in terms of

discount plan

Geographic Area

Zip code(s)

Date Subscribed

MM/DD/YY

Digital Literacy Program Offered?

Yes/No

Digital Literacy Offer Accepted at

Enrollment?

Yes/No

Only enter if literacy program is offered to

subscriber

17

image07-00.jpg792x612

SUBSCRIBER-LEVEL INFORMATION PROVIDED BY ETC

BLOCK F

Each ETC is required to submit the information contained in block "Follow-Up and Retention Information – Block F" based on subscriber

records within three months after the subscriber received the last discount in the pilot. Each subscriber must have a unique identifier, which

will be used throughout the study, assigned by the ETC (Unique Subscriber Identifier).

Block F

Question

Response

Notes

Unique Subscriber Identifier

Unique, anonymized identifier assigned by the

ETC

Project Code Identifier

Identifies the subscriber's study group in terms of

discount plan

Did the subscriber participate in the

study for the full duration of the

program?

Yes/No

Number of months of discount actually

received

0-12

If not currently subscribing, date

service ended

MM/DD/YY

If customer ended service, indicate date ended

Did subscriber retain service with the

ETC in the first month following the

last discount (i.e. the first

unsubsidized month)?

Yes/No

Did subscriber retain service with the

ETC in the second month following

the last discount (i.e. the second

unsubsidized month)?

Yes/No

Did subscriber retain service with the

ETC in the third month following the

last discount (i.e. the third

unsubsidized month)?

Yes/No

18

image08-00.jpg792x612

SUBSCRIBER-LEVEL INFORMATION COLLECTED FROM THE SUBSCRIBER

BLOCK G

Each ETC, or USAC if the ETC requests, is required to collect the information contained in block "Subscriber-Provided Information at Enrollment – Block

G" directly from each subscriber prior to providing a discount and submit when all subscribers have enrolled in the project. ETCs have the option of

having USAC collect this information through an electronic, online survey at enrollment; subscribers must consent to collection and sharing of this

information in order to receive any discount. Each subscriber must have a unique identifier, which will be used throughout the study, assigned by the

ETC (Unique Subscriber Identifier).

Block G

Question

Response

Notes

Unique Subscriber

Identifier

Unique, anonymized identifier assigned by

the ETC

Project Code Identifier

Identifies the subscriber's study group in

terms of discount plan

Subscriber Age

Ages of household

members

Number of household

members using

subsidized broadband

In 2011, what was this

household's total

income before taxes?

Less than $5,000, $5000-$9999

$10,000-$20,000, $20,001-$30,000,

$30,001 or more,

Not Determined

Equipment expected

to be used with

broadband service -

choose multiple

Desktop Computer, Laptop/netbook

computer, Tablet, Mobile device

(smartphone), mobile broadband modem

(aircard)

19

image09-00.jpg792x612

Has this consumer

subscribed to

broadband in the

past?

Never, Within last 3 months, Within last 6

months, Within last 12 months, More than

12 months ago

Monthly cost too expensive, didn't use

service, don't know how to use

computer/Internet, uncomfortable with

Internet (e.g. privacy concerns,

dangerous for children), happy with dial-

up, could access Internet elsewhere,

other – specify

Reasons for not

previously obtaining

broadband - can

choose more than

one

If subscriber

previously subscribed

to broadband, but

dropped service,

reason for dropping

(can choose more

than one response)

Monthly cost too expensive, didn't use

service, the equipment no longer worked,

don't know how to use computer/Internet,

uncomfortable with Internet (e.g. privacy

concerns, dangerous for children), happy

with dial-up, could access Internet

elsewhere

Answer NA if previous answer is "Never"

Want to stay in touch with family and

friends, children need it for school,

subscriber needs it for school, want to

access music, movies and other

entertainment, children want internet

access, get health care or medical

information, job required online access,

need it for job searches, want to share

photos or videos with family and friends,

internet provider offered a good price for

the service, use for daily activities (e.g.

check bus schedule), other --- specify

Reason(s) for use of

Internet (can choose

more than one

response)

20

image10-00.jpg792x612

SUBSCRIBER-LEVEL INFORMATION COLLECTED FROM THE SUBSCRIBER

BLOCK H

Each ETC, or USAC if the ETC requests, must collect the information contained in block “Follow-up and Subscriber Usage

Information – Block H” from the subscriber no later than the end of the project. ETCs have the option of having USAC collect this

information through an electronic, online survey; subscribers must consent to collection and sharing of this information in order to

continue receiving any discounted broadband service. Each subscriber must have a unique identifier, which will be used

throughout the study, assigned by the ETC (Unique Subscriber Identifier).

Block H

Question

Response

Notes

Unique Subscriber

Identifier

Unique, anonymized identifier assigned by the ETC

Project Code Identifier

Identifies the subscriber's study group in terms of

discount plan

Number of Household

members using

discounted broadband

service

21

image11-00.jpg792x612

Want to stay in touch with

family and friends, children

need it for school, subscriber

needs it for school, want to

access music, movies and

other entertainment, children

want internet access, job

required online access, need it

for job searches, want to

share photos or videos with

family and friends, internet

provider offered a good price

for the service, use for daily

activities (paying bills), other --

- specify

Subscriber use of

Internet (can choose

more than one

response)

Did the subscriber

participate or is

currently participating

in any training

programs so he/she

can better use a

computer and the

Internet?

No training class taken,

currently taking a training

class, completed a training

class

Desktop Computer, Laptop

Computer (includes netbook),

Tablet, Mobile Device

(Smartphone)

Mobile Broadband Modem

(aircard)

Equipment used with

service (can choose

more than one

response)

22

Note: We are currently transitioning our documents into web compatible formats for easier reading. We have done our best to supply this content to you in a presentable form, but there may be some formatting issues while we improve the technology. The original version of the document is available as a PDF, Word Document, or as plain text.

close
FCC

You are leaving the FCC website

You are about to leave the FCC website and visit a third-party, non-governmental website that the FCC does not maintain or control. The FCC does not endorse any product or service, and is not responsible for, nor can it guarantee the validity or timeliness of the content on the page you are about to visit. Additionally, the privacy policies of this third-party page may differ from those of the FCC.