U.S. USDA Form usda-rus-569
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number. The valid OMB control number for this information collection is 0572-0079. The time required to complete this information collection is estimated to average 4 hours per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
RURAL UTILITIES SERVICE - USDA
NAME OF BORROWER
LOCAL SERVICE DATA FORM
Instructions -
BORROWER DESIGNATION
PART A - AREA COVERAGE DATA - TOTAL SYSTEM
EXISTING
EXCHANGES
Use additional pages if necessary
Exchange
State
County
Access Lines
B1
R1
Other*
Rates
Total
B1
$
Total System
Comments:
(*Describe "Other" Access Lines)
RUS Form 569 (Rev. 9-03) Page 1
R1
$
PROPOSED
Access Lines
B1
R1
Other*
Rates
Total
B1
$
R1
$
RURAL UTILITIES SERVICE - USDA
NAME OF BORROWER
LOCAL SERVICE DATA FORM
Instructions -
BORROWER DESIGNATION
PART B - ADDITIONAL REVENUE PRODUCING SERVICES - TOTAL SYSTEM
(Annual)
CUSTOM CALLING, CLASS FEATURES
Description of Services
Existing
Number
Revenue
Proposed
Number
$
MOBILE TELEPHONE, CELLULAR, PCS
Description of Services
Existing
Number
Revenue
Proposed
Number
$
DIAL-UP INTERNET
Description of Services
Revenue
Proposed
Number
$
BROADBAND SERVICES, WIRED, WIRELESS, VIDEO
Description of Services
Revenue
Proposed
Number
$
OTHER REVENUE PRODUCING SERVICES
Description of Services
Revenue
$
Comments:
RUS Form 569 (Rev. 9-03 ) Page 2
Revenue
$
Existing
Number
Revenue
$
Existing
Number
Revenue
$
Existing
Number
Revenue
$
Proposed
Number
Revenue
$