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Services Reseller Agreements by llg16183

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									                2007 Lifeline, Link Up and Tribal Lifeline Services Certification

If CLEC is reselling or intends to resell Lifeline, Link Up and Tribal Lifeline Services, CLEC hereby
certifies that it has and will comply with all state and FCC requirements governing the Lifeline, Link
Up and Tribal Lifeline services programs as required by 47 C.F.R.§ 54.417. CLEC agrees to certify
annually to Qwest that it is and will remain in compliance with all state and FCC requirements as
required by 47 C.F.R.§ 54.417.

If Qwest has reason to believe that CLEC is not acting in accord with its certification, Qwest may
suspend, subject to any applicable federal or state rules or regulation, resale of the Lifeline, Link Up
and or Tribal Lifeline Service to CLEC and exercise its rights under the Resale or Interconnection
Agreement including provisions 5.18 and 18.0.

Reseller Name ___________________________________________________________

Reseller Address _________________________________________________________

Reseller Main Telephone Number ____________________________________________

Reseller Contact Telephone Number __________________________________________

Eligible Telecommunication Carrier (ETC) status is a criteria used by Qwest in the management of
resold Lifeline, Link Up and or Tribal Lifeline services.1 If CLEC is an ETC it will need to secure
TAP credits directly from the appropriate Federal and or State agency (ies) as Qwest will not collect
TAP credits on the ETC’s behalf.

Please select each state below in which CLEC is NOT an ETC. Qwest will make the necessary
updates to its systems to enable CLEC to resell these services for the states selected below (where
CLEC is NOT an ETC):

      Arizona                   Idaho-south                Montana                    South Dakota
      Colorado                  Iowa                       North Dakota               Utah
      Idaho-north               Minnesota                  Nebraska                   Washington
                                New Mexico                 Oregon                     Wyoming


I, _____________________________________ (signature of officer or other person authorized to sign
on behalf of Reseller), do hereby certify under penalty of perjury that
___________________________________________(Reseller’s name) is and will remain in
compliance with all state and FCC requirements governing the Lifeline, Link Up and Tribal Lifeline
programs. I also certify under penalty of perjury that I am an officer of Reseller or I am otherwise
authorized to make this certification on behalf of Reseller.

Printed Name: ___________________________________________________________

Title: ___________________________________________________________________

1
    A CLEC is an ETC in a state if it has been designated as such in accord with 47 U.S.C. § 214(e).

                                                                                                           1
Date: ___________________________________________________________________

Failure to return an accurately completed Lifeline, Link Up and Tribal Lifeline Services (TAP)
certification form will result in removal of TAP credits.

This certification is valid for one calendar year and will require annual certification.

Submit original completed certification form to:

Qwest Corporation
Director Interconnection Agreements
1801 California, Room 2400
Denver, CO 80202




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