20130211FCC Form 555 Custer Telephone Cooperative.pdf

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I 3060-0819
FCC Form 555 '701 11 rt.D Ffl tC.
November 2012 Liii -•ju•.i
'sIS1ON
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 315'(Annualiy
Idaho
State
(An Eligible Telecommunications Carrier (ETC) must provide a certflcationformfor each state in which it
provides Lifeline service),
472218 Custer Telephone Cooperative, Inc.
Study Area Code(s) (SAC) ETC Name(s)
Custer Telephone Cooperative, Inc.
Holding Company Name(s) DBA, Marketing or Other Branding Name(s)
Affiliated ETCs (include names and
SACS, -F attach additional sheets ifnecessa,y)
Section 1: AIIEWs (Initial the certification that applies to your ETC. Depending on the state, both
certifications may apply).
1 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 spec/Ic SAC(q)for which you are making this certification if it is not applicable to all ofyour study
areas within the state. Attach additional sheets if necessary).
AND/OR
I certify that the company listed above confirms consumer eligibility by relying on Idaho Department of Health & Welfare
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 qua4fving programs (e.g., SNAP, 851) these sources are used to verify consumer eligibility). I am an
officer of the con,ppy named above. I am authorized to make this certification for the Study Area(s) listed
above. Initial
472218
(List the snecific SAC(s) for which you are making , this certification if it is not avnlicable to all of your study
areas within ihe state.Attach additional sheets if necessary).
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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 cojipny 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 May FCC
Form(s) 497 Form(s) 497
Provided to
Wireline
Resellers
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 Dc- Subscribers Who
Contacted Directly Responding to Subscribers Responding That Enrolled or Dc-Enrolled Prior
to Recertify ETC Contact They Are No Scheduled to be to Rocertificction
Eligibility Through Longer Eligible Dc-Enrolled as a Attempt
Attestation Result of Non-
Response or
Ineligibility
I J K L
Number of Number of Customers Dc- Number of Subscribers Who Dc-Enrolled
Number of Subscribers Subscribers Whose enrolled or Scheduled to be Dc- 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
106 7
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3060-0819
FCC Form 555
November 2012
[SItI
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
(List the specific SAC(s) for which you are making this certification if it is not applicable to all ofyour study
areas within the state. Attach additional sheets fnecessary.
Section 3: All ETGs ('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 co p ny named above. I am authorized to make this certification for the Study Area(s) listed
above. Initial
Section 4: Non -Usage Applicable to Certain Pre-Paid Elt's (the ETC does not assess or collect a monthlyfee
from its Lifeline subscribers)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
, LC
Signature of Officer
General Manager
Title of Officer
Dennis L. Thornock
Dennis L. Thornock a
Printed Name of Officer
1/25/12
Date
208-879-2281
Person Completing this Certification Form Contact Phone Number