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Home My WebLink About20130128FCC Form 555 Rural Telephone Company.pdf- Approved by OMB FCC Form 555 ZIBIMAR 19 FM 3• 35 3060-0819 November 2012 ,. TILMMISS1 O Annual Lifeline Eligible Telecommunications Carrier Certification Form All carriers must complete Sections 1, 2, and 3. Carriers must complete Section 4, if applicable. Deadline: January 31s(A nnually) Idaho State (An Eligible Telecommunications Carrier (ETC) must provide a certification form for each state in which it provides Lifeline service). 472233 Rural Telephone Company Study Area Code(s) (SAC) ETC Name(s) Rural Telephone Company RTI- Rural Telecom Holding Company Name(s) DBA, Marketing or Other Branding Name(s) Affiliated ETCs (include names and SACs, attach additional sheets if necessary) RT I Rural Telecom Section 1: All ETCs (Initial the certification that applies to your ETC. Depending on the state, both certifications may apply). I certify that the company listed above has certification procedures in place to review income and program-based eligibility documentation prior to enrolling a customer in the Lifeline program, and that, to the best of my knowledge, the company was presented with documentation of each consumer's household income and/or program-based eligibility prior to his or her enrollment in Lifeline. I am an officer of the company named above. I am authorized to make this certification for the Study Area(s) listed above. Initial (List the specific SA C(s) for which you are making this certification if it is not applicable to all ofyour study areas within the state. Attach additional sheets ifnecessaiy). AND/OR I certify that the company listed above confirms consumer eligibility by relying on______________________ prior to enrolling a customer in the Lifeline program. (Please list the program eligibility data sources, such as ETC access to a state database and/or notice of eligibility from the state Lifeline administrator and indicate for which qualifying programs (e.g.. SNAP, SSI) these sources are used to verify consumer eligibility). I am an officer of the company named above. I am authorized to make this certification for the Study Area(s) listed above. Initial S (List the specific SAC(s) for which you are making this certification if it is not applicable to all of your study areas within the state. Attach additional sheets ifnecessay). Approved by OMB 3060-0819 FCC Form 555 November 2012 Section 2: All ETCs (Initial the certification that applies to your ETC, and if applicable, complete columns A through L the tables below. Attach additional sheets if necessary). I certify that the company listed above has procedures in place to re-certify the continued eligibility of all of its Lifeline customers, and that, to the best of my knowledge, the company obtained signed certifications from all consumers attesting to their continuing eligibility for Lifeline, except those subscribers whose eligibility was verified by the company through the use of other sources of eligibility information as well as those subscribers who were re-certified by the state Lifeline administrator. Results are provided in the chart below. I am an officer of the company named above. I am authorized to make this certification for the Study Area(s) listed above. Initial A B Number of Number of Subscribers Lines Claimed on Claimed on May FCC MayFCC Form(s) 497 Form(s) 497 Provided to Wireilne Resellers 13 C D E"C-D F G=(E+F) H Number of Number of Number of Non- Number of Number of Number of Subscribers ETC Subscribers Responding Subscribers Subscribers De- Subscribers Who Contacted Directly to Recertify Eligibility Through Responding to ETC Contact Subscribers Responding That They Are No Longer Eligible Enrolled or Scheduled to be Dc-Enrolled as a De-Enrolled Prior to Recertification Attempt Attestation Result of Non- Response or Ineligibility I 1 i Ic L Number of Number of Customers Dc- Number of Subscribers Who Dc-Enrolled Number of Subscribers Subscribers Whose enrolled or Scheduled to be De- Prior to Recertification Attempt Whose Eligibility was Eligibility Was Enrolled as a Result of a Finding Reviewed By State Examined by State of Ineligibility Administrator or By Administrator or By ETC Access to Eligibility ETC Access to Data Eligibility Data and Found to be I Ineligible 13 1 Approved by OMB 3060-0819 FCC Form 555 November 2012 LS1 I certify that my company did not claim federal Low Income support for any Lifeline customers prior to June - (insert current year). I am an officer of the company named above. I am authorized to make this certification for the Study Area(s) listed above. Initial (Liit the specific SAC(s) for which you are making this certification if it is not applicable to all of your study areas within the slate. Attach additional sheets if necessary). Section 3: All ETCs (Initial the certification below). I certify that the company listed above is in compliance with all federal Lifeline certification procedures. I am an officer of the company named above. I am authorized to make this certification for the Study Area(s) listed above. Initial I w) Section 4: Non-Usage Applicable to Certain Pre-Paid ETCs (the ETC does not assess or collect a monthly fee from its Lifeline subscribe rs)(Record the number of subscribers de -enrolledfor non -usage by month in column N below). M N Month Subscribers Dc-Enrolled for Non-Usage January February March April May June July August September October November December Signed, Signature of Officer/' Pjsident Title of Officer Theresa Wilson James Martell Printed Name of Officer 01/10/13 Date 208-366-2614 Person Completing this Certification Form Contact Phone Number