FUSF Exemption Certification Instructions

Federal Universal Service Fund Surcharge Exemption Certification

Address:

State:

Postal Code:

Certified: Request BAN(s) Exempt

Non-Exempt

Form 499 Filer ID:

Rep. Name:

Title:

Telephone:

E-Mail:

Certification: On behalf of the carrier identified on this exemption certification, I hereby certify that:

1. The interstate special access telecommunications services (“telecommunication services”)purchased under the Access Carrier Name Abbreviation (ACNAs) and/or Billing Account Numbers (BANS) above are exempt from assessment by Hawaiian Telcom of an FUSF surcharge because the named carrier (1) incorporates the purchased telecommunications services into its own telecommunications service offerings to end user customers; (2) does not resell the purchased telecommunications services as information services; and (3) contributes directly to the FUSF based on revenues from such telecommunications services sold to end user customers. 2. I am authorized to submit this certification for the specific ACNA and/or BANs listed above on behalf of the customer with the associated the Form 499 Filer ID No. named on this certificate. If the FUSF surcharge exempt status of any service(s) purchased under any ACNA and/or BAN provided on this exemption certification is determined to be invalid, the customer accepts sole responsibility for any resulting FUSF payments that may be owed, including interest, and any other fines and/or penalties that may be assessed by the Federal Communications Commission.

3. The customer represents and warrants that (1) the information provided in the certification form above is accurate and complete to the best knowledge of the customer(s) and that Hawaiian Telcom may rely on such information for administering its FUSF obligations; and (2) if the status of telecommunications services purchased under any ACNA and/or BAN certified herein changes, it will notify Hawaiian Telcom within 30 calendar days by amending this certification as appropriate.

The individual named below is an officer of Customer and is duly authorized by Customer to make the representations, attestations, and certifications contained herein on behalf of Customer.

Customer

A PDF copy of the signed By: Original must be sent to Hawaiian Telcom at: Printed Name of Officer: [email protected] Title of Officer: OR Date: A copy of the signed original must be faxed to Hawaiian Telcom at: Fax Number: (808) 546-6358