20131016Inland Telephone ETC and FCC 481.pdf

INLAND TELEPHONE CAMPANY
Corporate Otfices
103 S. Znd St.
P.O. Box 171
Roslyn, WA 98941
INLAND
TELEPHONE
Telephone: [phone]
Fax: [phone]
October 15, 2013
Via email in .PDF format to iean.-ieutell@',uc.idaln.aou
Idaho Public Utilities Commission
Commission Secretary
472 W. Washington
P.O. Box 83720
Boise, ID 8372O-OO74
b tv?-f- t3- 0 )
Re: SIC Docket No. 1O-9O - FCC Form 481-Carrier Annual Report and
Report and Certification Pursuant to IPUC Order No. 29841
Dear Ms. Jewel:
Enclosed is a copy of the Federal Communications Commission ('FCC"),
Form 481 that was electronically completed and submitted to the Universal
Service Administrative Company fUSAC"). This submission is for Inland
Telephone Company, Study Area Code 472423 and includes all attachments
that were submitted to USAC and will be submitted to the FCC; the Idaho
Public Utilities Commission Certifications, Reports and Affidavit are included.
Since the Company serves a portion of tJre Nez Perce Reservation and/or
tribal members thereol these documents have also been sent to the Tribal
Chairman. If you should have any questions, please call me at (509) 649-22LL
or contact me by email at [e-mail].
Enclosures
Sincgqely,
Cames K. Brooks
Treasurer/Controller
Jean Jewel
September 15, 2OL3
Page 2 af2
CERTItr'ICATE O.tr. SERVICE
I, James K. Brooks, hereby certiff that I have, on this 15e day of
October, 2OL3, served the foregoing ELIGIBLE TELECOMMUNICATIONS
CARRIER (ETC) ANNUAL RE-CERTIFICATION upon all parties believed to be of
interest in this proceeding. A copy of the foregoing ELIGIBLE
TELECOMMUNICATIONS CARRIER (ETC) ANNUAL RE.CERTTFICATION fiIed
today was placed in the United States mail, first-class postage pre-paid,
overnight delivery service or electronically, as applicable, to the following:
Ms. Jean Jewel, Executive Secretary
Idaho Public Utilities Commission
47 2 W . Washington Street
Post Oflice Box 83720
Boise, Idaho 8372O-OA7 +
Electronically to: [e-mail]. gou
Marlene H. Dortch
Office of the Secretary
Federa-l Communications Commission
9300 East Hampton Drive
Capital Heights, MD 20743
Electronically (when available) to: apps.fcc.gou/ ecfs/
Nez Perce Tribal Executive Committee
Silas C. Whitman, Chai.rman
Post Office Box 305
Lapwai, ID 83540
Via USPS
STATE OF IDAHO
ELtctBLE TELECOiIMUNICATTONS CARRTER (ETC) ANNUAL
RE.CERTIFICATION
CONTENTS
Section 1: Carrier lnformation
Section 2: Description of Local Usage Plan
Section 3: Detailed Outage lnformation
Section 4: Unfulfilled Service Requests
Section 5: Customer Complaints
Section 6: Service Quality and Consumer Protection Certification
Section 7: Ability to Remain Functional in an Emergency
Section 8: Voice Telephony and Broadband Service Price Offerings
Section 9: AdditionalVoice Rate Dala
Section 10: Federal USF High-Cost Support Certification
Section 1 1: Five-Year Network lmprovement Plan and Progress Report
lD Annual ETC cert-modified JB Page 1 of8 08/13
Section 1 : Eligible Telecommunication Carrier Information
Date of ETC Annual Report August 26,2A13
Company Name: lnland Telephone Company
Address: 103 S 2nd Street
P.O. Box 171
Roslyn, WA 98941
Company Contact Personffitle: James K. Brooks, Treasurer/Controller
Tefephone Number: [phone]
Email Address: [e-mail]
Service Area Code (SAC): 472423
Number of ldaho Telephone Service Assistance Program (ITSAP) recipients: 5
(Use numberftom last report submifted to the ITSAP Administrator)
lD Annual ETC cert-modified JB Page 2 of I 08/13
Section 2: Description of Carrier's Local Usage Plan--
Competitive Eligible Telecommunications Garrier (CETC) Only
EfCs musf submit information describing the terms and conditions of any voice telephony seruice plans offered to
Lifeline and ITSAP subscribers, including details on the number of minutes provided as paft of the plan, additional
charges, if any, for toll calls, and rates for each such plan. To the extent the ETC offers plans to Lifeline
subscnbers that are generally available to the public, it may provide summary information regarding such plans,
such as a link to a public website outlining the terms and conditions of such plan. C.F.R. $ 54.202(a)(5).
Description: Not applicable: lnland Telephone Company is an incumbent localexchanqe
carrier with no varvino service olans.
Section 3: Detailed Outage lnformation 554.313(aX2)
Provide detailed information on any outage, as that term is defined in 47 C.F.R. $ 4.5, of at least thirty (30)
minutes in duration for each service area in which an EfC is designated for any facilities it owns, operates, /eases
or otherwise uses and that potentially affect (a) at least ten percent of the end users serued in a designated
seruice area; or (b) a 9-1-1 specialfacility, as defined in 47 C.F.R. $ 4.5(e). Specifically, the annual report must
include information detailing: (a) the date and time of onset of the outage; (b) a brief desciption of the outage and
its resolution; (c) the sfeps taken to prevent a similar situation in the future; and (f) the number of customers
affected. Reporting peiod is January*December 2012. See Oder No. 29841, page 18.
Number of outages:one (1)
Additional outage information: ln the Lenore exchanqe, on 10/26/2012 at 09:05. lost
connection with CenturvLink: approximately 294 subscribers were without lonq distance
service or connectivitv to 911: Centurvlink ticket # MA1007062. Service was restored by
Centurvlink on 10/2612012 at approximatelv 09:15: not certain what other steps can be taken
to prevent this from happeninq in the future other than establishinq another interexchanqe
route.
lD Annual ETC cert-modified JB Page 3 of 8 08/'13
Section 4: Unfulfilled Service Requests 954.313(a)(3)
Provide the number of reguesls for seruice from potential customers within the EfC's service area(s) that were
unfulfilled in the previoul year (January-December 2012). The ETC shall also detail how it attempted to provide
seruice to those potential cusfomers. See Order No. 29841, page 19.
Voice
The number of unfulfilled service requests from potential customers within the ETC's service
area: zero (0)
Additional information: There were no unfulfilled service requests for the period Januarv 1,
2012 throuoh December 31. 2012.
Broadband
The number of unfulfilled service requests from potential customers within the ETC's service
area: zero (0)
Additional information: There were no unfulfilled service requests for the period Januarv 1.
2012 throuoh December 31. 2012.
Section 5: Customer Gomplaints 554.313(aX4)
Provide the number of complaints per 1,000 handsets or lines for the previous year (Januaryr-December 2012).
Voice
The number of customer complaints per 1,000 handset or working access lines: zero (0)
Additional information: The Companv did not receive from the Federal Communications
Commission, the Consumer Protection Division of the Office of the Attornev General for the
State of ldaho or the Consumer Assistance Section of the ldaho Public Utilities Commission
("lPUC"). anv complaints against the Companv concerninq the services orovided to its
customers bv the Companv that are either subject to the requlatorv jurisdiction of the IPUC or
among the services supported bv the federal hiqh-cost fund.
Broadband
The number of customer complaints per 1,000 handset or working access lines: zero (0)
Additional information: The Companv did not receive from the FederalCommunications
Commission, the Consumer Protection Division of the Office of the Attornev General for the
State of ldaho or the Consumer Assistance Section of the ldaho Public Utilities Commission
("!PUC"). any comolaints aqainst the Companv concerninq the services provided to its
customers by the Companv that are either subiect to the regulatory jurisdiction of the IPUC or
among the services supported bv the federal hioh-cost fund.
lD Annual ETC cert-modified JB Page 4 of 8 08113
Section 6: Service Quality and Consumer Protection Certification
S54.313(aX5)
Prcvide certification that the canier is complying with applicable seruice quality standards and consumer
protection rules.
Section 7: Ability to Remain Functiona! in Emergencies Gertification
S54.313(aX6)
EfCs masf demonstrate that it has a reasonable amount of back-up power to ensure functionality without an
external pawer source, is able to re-route tratric around damaged facilities, and is capable of managing traffic
spikes resulting from emergency situations.
l, James K. Brooks, being of lawful age, state that I am Treasurer/Controller of lnland
Telephone Company ("Company"), that I am authorized to execute this certification on behalf
of the Company, and that the facts set forth in this certification are true to the best of my
knowledge, information and belief.
On this basis, the Company certifies to the ldaho Public Utilities Commission, pursuant
to 47 C.F.R. S 64.2009(e), that the Company's operating procedures are adequate to ensure
compliance with the Customer Proprietary Network lnformation rules and regulations as set
forth in 47 C.F.R. SS 64.2001 through 64.2009.
The Company further certifies that it maintains back-up power to ensure functionality
without an external power source in the forms of auxiliary generators and batteries in its central
offices as well as adequate battery back-up in its subscriber carrier cabinets and that its
switching capability is more than adequate to manage the traffic of its subscribers.
For calls within the exchange of Leon, depending upon where a cut is made, there
exists redundant toll routing however, in the Lenore exchange, there is no redundant toll
routing. ln both exchanges, the customers can continue to make calls within the exchange
should the interexchange facilities to CenturyLinUQwest or any intra-exchange facilities are
cut. The Company does not have ring technology at this time. The Company has secured an
RUS loan and purchased property in order to erect a tower to place microwave equipment for
a redundant route from the Lenore exchange.
I certify under penalty of perjury under the laws of the State of ldaho that the foregoing
is true and correct.
Dated this day of August, 2013 at Roslyn, Washington.
By:
K. Brooks
reasurer/Controller
lnland Telephone Company
lD Annual ETC cert-modified JB Page 5 of 8 08/13
Section 8: Voice Telephony and Broadband Price Offerings $54.313(aX7)
Caniers shall report rates in effect as of January 1. (This data is not required for the 2013 filing.)
per month; $0.
Section 9: Additional Voice Rate Data S54.313(h)
All incumbent local exchange canier recipients of hrgh-cosf s uppoft must repoft all of their flaf rates for residential
local seruice, as wellas sfate fees as defined pursuant to $5a318(e) of this subpaft. Caniers musl a/so repoft all
rafes fhat arc below the local urban .a,te floor as defined in $54.318 of this subpaft, and the number of lines for
each rate specified. Caniers shall report lines and rates in effect as of January 1.
Note: 5 TAP subscribers not included
v
Exchange Rate
Type
Residential
Local
Service Rate
State
Subscriber
Line Charge
State
Universal
Service Fee
Mandatory
Extended
Area Service
Charoe
Total
Leon FR $25.76 0 $0.23 0 $25.99
Leon MS $16.00 0 $0.23 0 $16.23
Lenore FR $25.76 0 $0.23 0 $25.99
Lenore MS s16.00 0 $0.23 0 $16.23
NOIEi Measurad service minutes oer month: $0.03/min thereafter.
Exchange Res.
Rate
State
Reg. Fee Total
Download
Speed
(Mbos)
Upload
Speed(Mbos)
Usage
Allow
(GBI
Usage action
Exchange/Description Lines Residential
Rate
State
Subscriber
TAP Line
Charoe
State USF
Surcharge
County E-
911
Surcharge
Leon-Basic Residential 28 $25.76 $0.07 $0.1 5 $1.35
Leon-Local Measured Svc 2 $16.00 $0.07 $0.15 $1.35
Lenore-Basic Residential 276 $25.76 $0.07 $0.15 $1.25
Lenore-Local Measured Svc 13 $16.00 $0.07 $0.1 5 $1.25
lD Annual ETC cert-modified JB Page 6 of 8 08/13
Section 10: Federal USF High-Cost Support Certification S54.313, 554.314
Pursuant to FCC regulations, in order for EfCs to continue to receive fedenl USF, the Commission "must file an
annual certification with the Administntor IUSACJ and the Commission IFCC] stating that all federal high-cost
suppoft provided to such caniers within that State will be used only for the provision, maintenance, and upgrading
of facilities and seruices for which the support is intended."
State of WASHINGTON) CERTIFICATION BY ELIGIBLE TELECOMMUNICATIONS CARRIER
) ss OF COMPLIANCE WITH SERVICE QUALITY AND CUSTOMER
County of KITTITAS ) PROTECTION, ABILITY TO REMAIN FUNCTIONAL lN EMERGENCIES,
AND USE OF FEDERAL HIGH-COST SUPPORT.
AFFIDAVIT OF BUSINESS OR CORPORATE OFFICER
The ldaho Pubtic Utilities Commission Order No. 29841requires that Eligible Telecommunlcations Caniers certify
that it is compliant with applicable service quality standards and consumer protection rules; and ETCs must
demonstrate the ability to remain functional in emergencies. ln addition, the Commission must file an annual
certification with the USAC and the FCC that all federal high-cost support provided to ETCs within the State of
ldaho will be used only for the provision, maintenance, and upgrading ol facilities and services for which the
support is intended. Accordingly, the undersigned states and verifles under oath the following:
1. I am an officer of lnland Tetephone Company, an eligible telecommunications carrier for receiving federal
universal service support under section 214(e) of the Telecommunications Act of 1996 in the state of
ldaho.
2. I am familiar with the Company's dayto-day operations in the state of ldaho and with the State's service
quality standards and consumer protection rules as set forth in Commission Order No. 29841.
3. lnland Telephone Company is complying with applicable service quality standards and consumer
protection rules of the FederalCommunications Commission and the ldaho Public Utilities Commission.
4. I certify to the Commission that the Company is able to remain functional in emergencies as set forth in
Commission Order No. 29841 and in 47 C.F.R. $ 54.201(a)(2).
5. I also certify that all federal universal service support funds received by lnland Telephone Company
during the cunent calendar year will be used in a manner consistent with section 254(e); that is, for the
provision, maintenance, and upgrading of facilities and services for which the support is intended. The
company will continue to comply for the period of January 1,2014, through December 31, 2014, to be
eligible for federal universal service fund support.
6. This verification and affidavit is provided to be the ldaho Public Utilities Commission to enable the IPUC
to certify to the FCC that federal universal service support received by the eligible carriers in the state will
be used in a manner consistent with Section 254(e) of the Telecomm
reasurer/Controller
Act.
SUBSCRIBED AND SWORN to before me thiq-](F
PAIdELA R. NELSON
NOTARY PUBLIC
STATE OF WASHINGTON
COMMISSION EXPIRES
SEPTEMBER 9.2015
lD Annual cert Page 7 of 8 08/'13
Section 11: Five-Year Network lmprovement Plan and Progress Report
The annual repoft must include a progress report on the caniels five-year seruice qualtty improvement plan,
including maps detailing its progress toward meeting the plan targetg an explanation of how much univercal
seruice suppott was received and how ff was used to improve signal quality, covenge, or capacity, and an
explanation regarding any network improvement tarurets that have not been fulfilled. This information shall be
submitted at the wire center level. The annual rcport must a/so include an updated five-year network
improvement plan indicating plans for future investment.
lnland Telephone Company has made substantial investments over the years, which
allow it to provide quality telecommunications servaces to its customers in its designated
Eligible Telecommunications Carrier ("ETC") service area. Through the investments and
expenditures, the Company is able to continue to provide services at a level that the Company
believes meets the intent set forth in 47 U.S.C. S 254 of providing quality telecommunications
services to customers in the service area for which the Company is designated as an ETC.
The Company remains dedicated to establishing an alternative means of getting its
interexchange traffic as well as less expensive and faster broadband transport to the world.
The Company has identified that it should require two microwave towers (one at the Lenore
central office and one across the Clearwater River) in order to establish the connection in/out
of the Lenore exchange location; with additional co-locations or microwave transport from an
existing cellular carrier. A site across the Clearwater River has been purchased.
The Company has applied and received a loan with the Rural Utillties Service ("RUS")
for approximately $4,100,000. The loan design'is to build a new central office building
($244,000), additional switching software ($14t,000), microwave facilities (towers and
equipmentx$1,183,000) and build fiber to the node (buried fiber and electronicsX$2,489,000).
The Company's contracted consulting engineers have been in the field performing staking and
design, however, with the changes to lnter-Carrier Compensation and Universal Service Funds
created by the Federal Communications Commission, with the exception of the microwave
facility, the Company is proceeding cautiously and does not have an anticipated timeline for
these projects at this time however, the Company has five years in order to draw these funds
from the RUS; by May 18,2017.
The Company has and will continue to make investments and expenses for the
provisioning, maintenance and upgrading of the facilities for which the Universal Service Fund
support is intended. Other than those investments contemplated by the RUS loan, the
Company has no further capital budget items for the period January 1,2013 through
December 31,2017 . The Company expects that levels of expenses will remain relatively
similar as those it experienced in the calendar year 2012, subject to the effects of inflation and
other commonly experienced changes in the cost of labor and materials; provisioning and
maintenance always continues.
The Company reports that, for the period January 1,2012 through December 31,2012, ,l
received $459,544 in Federal Universal Service Support from the High Cost funds.
lD Annual ETC cert-modified JB Page I of 8 08/13
INIA,ATDWLEPTIONE
Febrnary 25,2013
Wa Federal Express ouemight deliuera
Marlene H. Dortch
Ofhce of the Secretarlr
Federal Communications Commission
445 lzttt Street SW
Suite TW-A325
Washington, DC 20.554
llfith a delivery address of:
9300 East Hampton Drive
Capital Heights, MD 20743
(202',1418-0300
Re: EB Docket I{o. O6-36
Annual Section 64.2009 (e) Certifrcation
As required by section 64.2OO9(e) of the Federal Communications
Commission's rules, enclosed is an original and four copies of the
Customer Proprietar5r Network Information Compliance Certifi cation
enecuted by Inland Telephone Company, Form 499 Filer ID 80229. Also
enclosed is the Statement Regarding Operating Procedures for Inland
Telephone Comparry.
If you should have any questions, I can be contacted at {5O9) 649-
2217.
Enclosures
Cc: Best Copy and Printing, Inc (via email to FCCIdBCPIWEB.COMI
FCC Enforcement Bureau
airres K. Brooks
ANNU.A,L SECTION 64.2009(e) CERTIFICATION
EB DocketNo.06-36
Annual $ 6a.2009(e) CPNI Certificatlon lor 2012
Drted: February 25, 2013
Company: Inland Telephone Company
Form 499 Filer ID Numberz802299
Name of Signatory: James I(. Brooks
Title of Signatory: Treasurer/Controller
I, fames IC Brooks, cediry that I am a duly authorized officer of Inland Telephone
Company ("Inland" hereafter) and, acting as an agent of Iulan4 that I have personal lcrowledge
that Inlaud has established operatiug procedures ttrat are adequate to ensure complianoe wi& the
Customer Proprietary Network Infonaatior (*CPNI') rules of the Federal Communications
Commission ("Commission'), codified at 47 C.F.R Part 64 Subpart U, implementing Section
222 of the Communications Act of 1934, as amended.
Attached to this certification is an accompanyrng staterneut explaining how Inland's
procedures ensure &at the company is in complianoe with the requirements set forth in section
64.2001et seq. of the Commission's rules.
Inland has not taken any actions (proceedinp instituted or petitions filed by Inland at
either state commissions, the court system, or at the Commission against data brokers) against
data brokers in the past year. During the calendar year ended December 31, 2012, Inland did not
acquire first-hand any information that it has identified as being information with respect to the
processes pretexters are using to attempt to access CPM.
Inland has not received any customer complaints in the past year conceming the
unauthorized release of CPM.
STATEMENT REGARDING OPERATING PROCEDTJRES
IMPLEMENTING 47 C.F.R. PART 64 SUBPART U
GOVER}IING USE OF
cusToMER PROPRTETARY NETWORK INEORMATTON (CpNr)
MARCE t,2ol3
The foilowing statement explains how the operating procedures of Inland Telephone
Company ("Inland" or "Company'') ensure that it is in compliance with the Commission's CPNI
rules, as codified at 47 C.F.R. Part 64 Subpart U ($$ 64.20AL64.2011) and is relevant to
calendar year 2012. Except as othenrise indicated, the following applies with respect to the
Commission's rules in effect both before and after the December 8, 2007 effective date of the
Commission's April 2,2007 Report and Order in CC Docket No. 96-l L5. See FCC A7-22 (rel.
Apr. 2, 2AO7); Public Notice, DA 074915 (rel. Dec. 6,2007), This statement covers calendar
year2012.
I. Use of customer proprietary network information without customer approval.
A. Inland may use, disclose, or permit acoess to CPM for the purpose of providing or
marketing service ollerings among the categories of service to which the customer already
surbscribes from Inland, without customer approval.
B. krland may not use, disclose, or permit access to CPNI to market to a customer,
service offerings that are wiflrin a category of service to which the subscriber does not already
subscribe from Inland, unless krland has customer approval to do so, except as described in
Section I.C-
(1) Inland may use, disclose or permit access to CPM derived from their
provision of local exchange service or interexchange service, without customer approval,
for the provision of CPE and information servicos, such as call answering, voice mail or
messaging, voice storage and retrieval services, and fa"r storage and retrieval services.
Q) krland may not use, disclose or permit &ccess to CPNI to identiff or track
customers that call competing service providers except for CPM made available to other
telecommunications cariers pursuant to tariffed or detariffed billing and collection
arrangements and biUing and collection services provided pursuant thereto. The
Company does not sell CPM to any third-parly for any purpose.
C. Inland may use, disclose, or pemrit access to CPM, without customer approval, as
follows:
(1) Inland may use, disclose, or pemrit aceess to CPM, in its provision of
inside wire installation, nraintenance, and repair services.
(2) Inland may use CPNI to market services formerly known as adjunct-to-
basic services, such as, but not limited to, speed dialing, computer-provided directory
assistance, call monitoring, call tracing, call blocking, call rehm, repeat dialing call
tracking, call waiting caller I-D., call fonrarding and certain Centex features.
D. Inland may use, disclose, or permit access to CPM to pnctect lnland's rights or
properfy; to protect its users and other carriers from &audulent, abusivq or unlawful use o{, or
subscription to, Inland's services; and to render, provision, bill or collect for servioes.
Iuland provfules local erchange telephone sen'ice ofid access to long clistance service
provlders rn siu exchanges ln the states of ldoho aad lllashlttgton. Inland's operafing
procedures conryly with the dbove requirearcnts ond lnclude, bnt are uot lindted to, the
pt'ovisions descrtbed below. Tlrc Company does uot engage in any outbourtd telennrkahrg,
Outbound print arurkethry, lf any, that nny be dislrlbated by the Conryany by nail is
addressed to all srtbscribers ot custourcrs within the appllcable geographic areo, zlp code(s)
atd/or telephone nrunber preftx(es), withont regarul to the speeific services that the snbscriber
or custoiler receives, or does uot recelve, fron lhe Conryany and/ot'the Contpatty's afiliiles.
Under Conryany pollcy, noue of the Company's affiiates is perniile.d to nse ouy CPNI olthe
Conpanyfor oty orttboundtelematketing or ontbotud prilrt nnrketilry.
Moreover, the Conrpany does ilot nse oily CPMfor any inbound marketing of ser'vlces
tlnt are not withitt a category of service (1,e,, local and iuterqtchaage) to tphich the anstonrcr
olready subscrib* frorrt the Conryauy ailcVor orte or more of the Conrpany's affiiates. The
Coatpouy does not sell, or provide access to any third party tu, aily of the Compauy's CPNIfor
purposes of mark*ing the serulces of the Conpany or of cny of i* alftliates, other tlun as
pernitted without prior actomer approval with respect to the Conrpany's afflliat* Exceptfor
CPNI nnde avollnble to other teleconmrunications carriers pursttorrt to tarffid or detadlfed
bllling snd colleaiol orrdngeutents nnd btllirrg and colleaton services provided pursuarrt
thereto, aud pursuont to Connission-nmtdated carrier change pruceduresr lhe Coatpany does
rtot provide CPNI to auy third-pa@fot ilny purpose.
The Conryany, tts eruployees aud agents may amke sach ather uses and disclosurcs of,
and pernit access to, CPNI withottt cusloarcr approval os are penrtitted by applicable sldutq
rulq rcgulatlon or orden Such uses, disclosures or sccess any include those authorized by
Sectiotts 222(c) and (d) of the Connruilicatiorts Act of 1934, as amended, by Seaion 61.2005
of the Conmissiort's rnles and by orders of the Connission,
Escept as set fonh abovq the Conrpony does not provide any CPM to auy
govenmrental entity, or to aty other lhiruI pafly, other thott: pursuaul to sttbpoeua or other
lawfiil process or with the sabscrlber's pfior wrltteu corrsenl, or in accordance with the
authentlcatlon ad other requlrement desefibed at Sectiort IV below and in the FCC's rales,
as a result of aperson represeiltfurg hilnself or herself to be the subscrlher (or the subscrlber's
dul! strlhsrlzod agent) and having confinned his or her ldentlty or auilrcrtgt by providing to
the Company approprlate tdeutlfytrtg firformation (such as Social Securtty Nuntber, drlver's
llcense urunber, nruther's nniden ,tdnrc, ilser nane or pasnoord, ns approprlate or otheneise
required).
il. Approval required for use of customer proprietary network iuformation.
A. Inland may obtain customer approval through written, oral or elechonic methods.
(1) Inland does not seek or obtain oral approval, and therefore does not bear
the burden of demonsbating that such approval has been given in compliance with the
FCC's rules.
(2) A customer's approval or disapproval obtained by krland to use, disclose,
or permit access to the customer's CPM, the use of CPNI outside of the customer's total
service relationship with Inland must remain in effect until the customer revokes or limits
such approval or disapproval.
(3) Inland must maintain records of notification and approval, whether oral,
written or electronic, for at least one year.
B. Use of Opt-Out and Opt-In Approval Processes.
(1) Except where use, disclosure, or access to CPM is otherwise pemritted
wiftout prior customer approval (as described above), Inland only uses, discloses or
permits access to CPNI upon opt-out or opt-in approval, consistent with Section 64.2AA7
of the Comrnissiou's rules and, byDecernber 8,2007, with the Commission's amended
rules. Inland's process is described in Section II.A above.
(2) Except for use and disclosure of CPM that is permitted without customer
approval under Section I, or that is described Section II.B, or as otherwise provided in
section 222 of the Communications Act of 1934, as amende4 Inland may only use,
disclose, or pernrit access to its customer's individually identifiable CPM subject to opt-
in approval.
The Compdny atrrently does uot use CPNI iu a nnnner that retlaires prior
custorner approvol. Shoultl Inland's policy change, howeverr lnland shall irnplattent
theforegohtg pollct* to ensure the FCC's rales are coatplled with.
III. Notice required for use of customer proprietary network information.
A. Notification, Gsnerally.
(1) Prior to any solicitation for customer approval, Inland must provide
notification to the customer of the customer's right to restrict use of, disclosure o[, and
access to that customer's CPNL
(21 hrland must maintain records of notification, whether oral, written or
electonic, for at least one year.
B. Individual notice to customers must be provided when soliciting approval to use,
disclose, or permit access to customerc' CPM.
C. Coutent of Notice.
Customer notification must provide sulficient information to enable the custorner to make
an informed decision as to whether to permit Inland to use, disclose, or permit access to, the
customer's CPM.
G) The notification must state that the customet has a righl and Inlaud has a
duty, under federal law, to protect the confidentiality of CPM.
@ The notification must speciff the !ryes of information that constitute
CPM and the specific entities that will receive ttre CPM describe the purposes for wbich
CPM will be used, and inform the customer of his or her rigbt to disapprove those uses,
and denyorwithdraw access to CPM at any time.
(3) The notification must advise the customer of the precise steps the
customer must take in order to grant or deny access to CPltII, and must clearly state that a
denial of approval will not affect the provision of any services to which the customer
subscribes. However, krland may provide a brief statemenl in clear and neutral language,
describing consequences directly resulting from the lack of access to CPNI.
(4) The notification must be comprehensible and must not be misleading.
(O If written notification is provided, the notice must be clearly legible, use
sufEciently large t1rye, and be placed in an area so as to be readily appareut to a customer.
(6) Uany portion of a notification is translated into another language, then all
portions of the notification must be hamlated into that language.
(7) Inland may state in the notification that the customer's approval to use
CPM may enhance Inland's ability to offer products and services tailored to the
customer's needs. Inland also may state in the notification that it may be compelled to
disclose CPM to any person upon affinnative written request by the customer.
(8) Inland may not include in the notification any statement attempting to
encourage a customer to freeze third-party access to CPM.
(9) The notificatiou must state that any approval or denial of approval for the
use of CPM outside of the seryice to which flre customer already subscribas from Inland
is valid until the customer alfirmatively revokes or limits such approval or denial.
(10) Inland's solicitation for approval must be proximate to the notification of a
customer's CPM rights.
D. Notice Requirements Specilic to Opt-Out
Inland must provide notiEcation to obtain opt-out approval thmugh electonic or written
methods, but not by oral conununicatiou (except as provided in paragraph F ofthis section). The
contents of any such notification must comply with the requirements of paragraph C of this
sEction.
(1) hrland must wait a 30-day minimum period of time after giving customers
notice and an opportunity to opt-out before assuming customer approval to use, disclose,
or pennit acsess to CPM. Inland may, in its discretion, provide for a longer period.
Inland rnust notiff customers as to the applioable waiting period for a response before
approval is assumed.
(i) In the case of an electronic form of notification, the waiting period
shall begin to run from the date on which the notification was sent; and
(iD ln the case of notification by mail, the waiting period shall begin to
run on the third day following the date that the notiJication was mailed.
(2) Insofar as Inland is using the opt-out mechanism, it must provide a Notice
to its customers every two years.
(3) If Inland uses e-mail to provide opt-out notices, it must comply with the
following requirements in addition to the requirements generally applicable to
notification:
(i) Inland must obtain express, verifiable, prior approval from
consumers to send notices via e-mail regarding its seryice in general, or CPNI in
particular;
(ii) hland must allow customers to reply directly to e-mails containiug
CPM notices in order to opt-out;
(iir) Opt-out e-mail notices that are returned to Inland as undeliverable
must be sent to the customer in another form before Inland may consider the
sustomer to have received notice;
(iv) Inland must ensure that the subject line of the message clearly and
accurately identifies the subject matter of ttre e-mail; and
(v) Inland must make available to every customer a method to opt-out
that is of no additional cost to the customer and that is available 24 hours a day,
seven days a week. Inland may satisff this requirement through a combination of
methods, so long as all customers have the ability to opt-out at no cost and Bre
able to effectuate that choice whenever they choose.
E. Notice Requirements Specific to Opt-In.
Inland may provide notification to obtain opt-in approval through oral, written, or
elechonic methods. The contents of any such notification must comply with the requiremeots of
paragraph C ofthis section.
F. Notice Requirements Specific to OneTime Use of CPNI.
(l) Inland may use oral notice to obtain limited, one-time use of CPNI for
inbound and outbound customer telephone contacts for the duration of the call, regardless
of whether Inland uses opt-out or opt-in approval based on the nature of the contact.
(2) The contents of any such notification must comply with the requirements
of paragraph C of this section, except that Inland may omit any of the following notice
provisions if not relevant to the limited use for which Inland seeks CPM:
(r) Inland need not advise customers that if they have opted-out
previously, no action is needed to maintain the opt-out election;
(ii) lnland need not advise customers that they may share CPNI with
their affiliates or third parties and need not name those entities, if the limited
CPM usage will not result in use by, or disclosure to, an afFliate or third partf
(iiD krland need not disclose the means by which a customer can deny
or withdraw ftture access to CPNI, so long as Inland explains to customers that
the scope of the approval krland seeks is limited to one-time use; and
(iv) Inland may omit disclosure of the precise steps a customer must
take in order to grant or deny access to CPNI, as long as Inland clearly
communicates that the customer can deny access to his CPNI for the call.
The Conrpaily currently d.aes not use CPNI fut a manter that requires prlor
custorrter approval. Shoald Inland's poliqy clrungq however, Inland shall intplanent
the foregoirtg pollcles lo ensure the FCC's niles are complied wlth.
ry. Safeguards requlred for use and disclosure of eustomer proprietary nehvork
information.
A. Inland must implement a system by which the status of a customer's CPNI
approval can be clearly established prior to the use of CPM. Inland's policies and procedures
are detailed in Section II above.
B. Effective December 8,2007,Inland may release call detail informatioa during a
customer initiated telephone contact only if reasonable authentication procedures are complied
with and (1) the customer provides Inland with a pre-established password" (2) Inlan4 at the
oustomer's request, sends the call detail information to the oustomer's address of record provided
the address of record has been associated with the account for at least thirty (30) days, or (3)
when Inland calls the telephoue number of resord to disclose flre call detail information. Inland
is permitted to create a back-up customer authentication method for lost or forgotten passwords.
Inland is also prohibited from releasing call detail information during a retail visit without the
appropriate password or valid photo identification
However, if the during a customer-initiated telephone contaot, the customer is able to
provide without assistance from Inland personnel all of the call detail information necessary to
address a customer service issue (i.e., the telephoue number called, when it was called, and if
applicable the amount charged for the call), then krland personnel are perrnitted to proceed with
its routine customer care procedures.
C. Not later than June 8, 2008, Inland must authenticate a customer without readily
available biographical or account information prior to allowing the customer on-line access to
CPM related telecommunication service account. Once authenticated, the customer may only
obtain on-line access to CPM related telecommunications service account through a password.
D. Effective Decsmber 8,2007, hland is required to notifu customers immediately
when a password or back-up means of authentication for lost or forgotten passwords, on-line
account, or address of record is created or changed. Such notification is not required when the
customer initiates service, including the selection of a password.
E. Business customers are exempt from the password requirements which became
effective December 8,200'1, if the customer is contractually bound to lnlan4 is serviced by a
dedicated Inland account representative as the primary coutact, and within the conEact krland is
responsible to address its CPNI obligations. I[, at any point, the business customer must go
through a call center to reach a customer service representative, then the exemption does not
apply.
F. Inland trains its personnel as to when they are and are not auflrorized to use CPM
and Inland must have an express diseiplinary process in place.
G. Inland must nraintain a record, elechouically or in some other manner, of its own
and its affiliates' sales and marketing campaigns that use its customers' CPM. Inland shall
maintain a record of all instances where CPM was disclosed or provided to third parties, or
where third parties were allowed access to CPM. The record must include a description of each
campaign, the specific CPM that was used in the campaign, and what products and services were
offered as a part of the campaign. Inland shall retain the record for a minimum of one year.
H. krland must establish a supervisory review prccess regarding its compliance with
the FCC's CPNI rules for outbound marketing situations and maintain records of its compliance
for a minimum period of one year. Specifically, sales personnel must obtain supervisory
approval of any proposed outbound marketing request for customer approval.
L Effective December 8,2007, hland must take rcasonable measures to discover and
protect against attempts to gain unauthorized access to CPN! which may include encrlptiou of
its databases. Inland must properly authenticate a customer prior to disclosing CPNI based on a
customer-initiated telephone contact, on-line account access, or an in-store visit.
krland must take measures to pmtect CPNI stored in its internal databases from potential
unauthorized access, and evaluate and increase its security measures should it discover an
increase in attempts to gain access to unauthorized information.
J. Inland must provide written notice within five business days to the FCC of any
instance where the opt-out mechanisms do not work properly, to such a degree that consumers'
inability to opt-out is nrore than an anomaly.
(1) The notice shall be in the form of a letter, and shall include Inland's nnnl€r
a description of the opt-out mechanism(s) used, the problem(s) experienced, the remedy
proposed and when it will be/was implemented, whether the relevant state commission(s)
has been notified and whether it has talcen any action, a copy of the notice provided to
customers, and contact information.
(2) Such notice must be submitted even if Inland offers other methods by
which consLlmcrs may opt-out.
I( Effective December 8, 2007, lnland has a general duty to first infonn federal law
enforcement agencies, followed up by notification to affected customers, after reasonable
determination of a breach of its customers' C?M.
(1) Inland must file an elechonic notification to the United States Secret Service
(USSS) and the Federal Bureau of Investigation (FBI) within seven (7) business days
through the central reporting facility fi,rmished by the Commission.
(2) hland is prohibited from noti$ing customers or the general public of the
breach until seven (7) bminess days have passed after notification to the USSS and FBI
unless under certain specified circumstances: (a) Inland identifies an "exEaordinary need
to notiff customers" before that period or (b) An ongoing or potential investigation or
national security requires customer disclosure to be potentially delayed for up to thirly
(30) dap. Inland must notiff the affected customer(s) ater the applicable period.
(3) Inland must maintain a record, whether elechonically or in some other marurer of
any breaches discovered, notifications made to the USSS or EBI and notifications made
to customers. Tho record must inolude, if available, dates of discovery and notification, a
detailed description of the CPNI tlrat was the subject of the breach, and the circumstances
of the breach. Records must be maintaiued for a two (2) yearperiod.
fnhud't operating procedures conryly utlth all of tlrc above requirearcnts, ittchtdirtg
those thal became elfective Decentber 8, 2407. lfiith respec't to ortline autheutication in
partiailar,Iuland huplenrcriled measures lo ensure coatpllauce by the applicable June 8, 2008
deadline As prevlonsly discussed, the Conryany cameutly does tot use CPNI ln a nnnner
that requires prior antonter approval Should hland's poliqr change, how*er, Inland sholl
implearcnl the relannt aforementloned policies to errstre the FCC's niles are coutplied wlth.
Inland notes ln porticulor thot:
t Conrpaty persomrcl arc trahrcd as to wheu they ore and are not aulhorlzed to use
CPNI, aul tlnt an a;press process is iu place such that violotlons of these procedures
nrcy result itt dlsciplinary action, up to aud irtcluding tenninatiort of employmenl
t lulaud does not provide atstomers'with ortllne access to their CPNI at thls tiua
c lllitlt respect to bashrcss cnstorrrers subject to Section IY.E abovq Inland reqalres theut
to provide the naarcs of all that are autlnrized to hrwe access to the occortttl aud al
firhat authorization level (ag. to anke sewice changes, reqaest additlortol serviees,
billirtg hqulrles) nnd further requires thol a 6 to l0glace alphanunrcric password be
estahlished.
. Operatlng procedures hm'e been lmplenenled to conryly wlth the reuainiug
reqairemeuts described above and appllcable lo Inland's usq dlsclosure of and thtrd
party access lo CPNL
V. Supplemental Information
Effective December 8,20A7, flre FCC's rules require that the annual certification filed
pursuant to 47 C.F.R. $ 64.2009(e) disclose any actions talcen against data brokers and a
summary of all oonsumer complaints received in ttre previous calendar year regarding the
unauthorized release of CPNL Inland is not aware of any consumer complaints regarding the
rurauthorized release ofCPM and has not taken action against any data brokers.
Approved by OMB
3060-08 I 9
FCC Form 555
November 2012
Annual Lifeline Eligible Telecommuuicatlons Carrier Certilicstion Form
All canien must complete Sections l, 2, and 3. Carriers must complete Section 4, if applicable,
Deadline: January 3 ln (Annually)
ldaho
State
(An Eligible Telecounnnications Carrier (ETC) t tust provide a cet'tfuationformfor each state lnwhlch lt
provides Lileline s eruice\.
47242e
Westem Elite lncorporated Services
!nland Telephone Company
ETCName(s)
lnland Networks
Holding Company Name(s)DBA, Marketing or Other Branding Name(s)
Affiliated ETCs (irrclude nanrcs and SiCs,Additional Sheet Attachedallach additlonal sheets if necessny)
Section l: All ETCs (Inltlal the certiJication that applie.s to yoar ETC. Depending on the state, both
cert iJi c at I ow mry app ly')-
I certiff that the company listed above has certification procedures in place to review income and program-based
eligibility documentation priorto enrolling a customer in the Lifeline progrsm, and that to the best of my
knowledge, the company was presented with documentation of each consltrner's household income and/or
program-based eligibiliry prior lo his or her enrollment in Lifeline. I am an officer of named above.
I am authorized to malce this certification for the Study Area(s) listed above. Initial
(List the specific &lC(s) for which you are nnHng this certlJlcalion if it is not appltcable lo all of yonr stndy
areas witll/ln the stote. Attach additional sheets if nec*saqi).
AND/OR
I certiff that the company listed above confirms consumer eligibility by relying on cAPA olkrrho
prior to enrolling a customer in the Lifeline program. (Please llst the program ellglbtllty data sources, such as
ETC access lo a slate database mrdlor notlce of ellgibilitjtfi'om tlv slale Lifelhte adntiltislrator md indicatefor
t ltich gualiflirrg progro,rrs (e,g., WA4 SS0 these sources are used lo verifit ss71s11rer eltgibillty), I am an
officer of the named above. I am autlurized to make this certification for the Study Area(s) listed
above, Inltlsl
(List the specific SAC(s) for which 1ou are nnking this certiJicatiott if it is not applicable to all
472423
Notice of eligibility is received via email from the Community Ac,tion Partnershlp Association (GAPA) of ldaho
areas vitlin the stale. Atlach additional sheels lf necexay).
'Your ilud1'
Approved by OMB
3060-08 i9
FCC Form 555
November 2012
Section 2: All ETCsllntttal tlrc certi/ication tlW applles to yonv 67r, md lf applicable, courylete calunns A
through L the lables belov- Attach addltlonal sheets if neceswry).
I certifr that the company listed above has pmcedures in place to re-certify the continued eligibility of all of ie
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
verifred by the company through the use of other sources of eligibitity information as welt as those subscribers
who were re-certified by the state Lifeline administrator. Results are provided in the chart below. I am an officer
named above. I am authorized to make this certification for the Study Area(s) listed above.
Numbcr of
LIncs
Clqlmed on
May FCC
Form(g).197
Prcvidcd to
Wlrcllnc
Rcscllcrs
c D E=C-D F G = (E+F)H
Number of
Subscribars ETC
Contoctcd Dircctly
to Rcccrtlfy
Ellglllillty Through
Atlcsl!tlon
Numbcr of
Subscrlbers
Rcspoarling to
ETC Contoct
Numbcr ofNoo-
Rcspouding
Subscrlbcrs
Numicr oI
Subscrlbcrs
Rerpondlng Thlt
Tbcy Arc No
Longcr Ellgiblc
Nsmbcr of
Subscribcrs Dc.
Earollod or
Schedulcd to Uc
Dc.Earolkd ls l
Result ofNon-
Rcrpoasc or
Inrlioibilitv
Numbcr of
Subscribsrg Who
Dc-Eorollcd Prlor
io Reccrtillculion
AltEruDt
I J K L
Number ofSubrcrlbcrr
rflhosc Eliglbillty wu
Rcvlcrrcd By Statc
Admlnlstralor or By
ETC Aecess lo Eliglbillty
Dlto
Numbcr o[
Subscrlhcn lVhosc
Eliglbillty lVls
Examincd by Slatc
Admluistrulor or By
ETC Accegs to
Ellgibllity Dilr and
Fonrd to bc
Inallolhh
Namhcrof Customers Dc-
cnrullcd or Schcdulcd lo bc De-
Enrollcd as a Rcsult ofr Flndlng
of hdigiblllty
Number otSubscribrt3 lYho IrFEnrollcd
Prior io Rcccrlllicltion Attcmpt
5 0 0 7
Approved by OMB
3060-0819
FCC Form 555
November 2012
OR
I certifr that my company did not claim federal Low Income support for any Lifeline customers prior to June _
(insert cun'ent yeat), I am an officer of the company named above. I am authorized to make this certificalion for
the Study Area(s) listed above. Initlal_
(List the specific SAC(s) for whlch you arc uruHng tltis certification if it is not appllcable to all of yow study
ueas vlthln the state. Attach dditlonal sheets if necasary).
Section 3: AII ETCI (Inltial the certlJication beloyD.
I certiff that the company listed above is in compliance with all federal Lifeline certification procedures. I am an
offtcer of tlrc company named above. I am authorized to make this certification for the Study Area(s) listed
above. lnitial/Wtr
Section 4: ttoo[Usage nppllcabte to Certain Pre-Patd ETCs (rhe ETC does tnl assess or collect a monthlyfee
from tts Lifeline subscribers)(Reeord tlte nunber of subscrlbers de-enrolledfor non-Nage by month in column N
below\
James K. Brooks
Printed Name of Officer
January 31, 2013
Daie
(509) 64e-2211James K. Brooks
M N
Month Subscribers De.Enrolled for Non-Usage
Januarv
February
March
April
Mav
June
July
August
September
October
November
December
Conlact Phone Number
Approved by OMB
3060-081 9
FCC Form 555
November 2012
Affrliated ETCs
sAc Name
5?2423 lnland Telaphore Gompsny (drbla lnlarut N€tworl<r,
52S003 WashlBglon RSA No. I Umiled Parlnsnhlp (dlbla lnland Cellulor)
529004 Emtsm Sub-RSA Llrnltad Parlnarrhlp (d/bra lnhnd Crltular)
47p007 Waahlnclon RSA No.8 Umll€d Parhenhlp (d/b/a lnland CalMar)
Approved by OMB
3060-081 9
FCC Form 555
November 2012
ETC ldendfication
sAc ETC Name
472423 lnlrnd TolaDhons Comoany
8;u027 InlEnd Telsphono Cdfl pEny
479007 Warhhslon RSA No. 8 Llmllad Parlnststilp
529003 Werhlnqton RSA No. 0 lJmltEd PBilnolthlp
52!1004 Eadom Sub-RSiA umllsd Parlnolthlp
Com s
sAc Holdins Comoanv Name
4724?3 Wolbm EmE lncorporslrd Sorvlcas
5?2123 WaslEm Ellla lncomoraled Servlceg
47S0['lnlad Celular Tclsohone Cornoenv
52s)03 lnland CEllul8r TE|lohon, ComlaIlv
52m04 lnland Csllular TaleDhons Gomf rry
DBA, MA or Other s
SAC Name
4721?5 lnllnd Nlbvorll8
5U42:t ldand Netuotlts
47S007 lnland Csllutr
52S003 lnlsnd Colld&
52S004 hl.nd Cdlular
Aodia3tot!cP4om*RrdugidAdofl995.8!8pty6rys.@dua6.F6.&d!D6nitDoltGqBi.tdtoEpotr,',u*,,*,-o,n,^^M*,ffJh1ts
OMB mtrd outq fqtur hfmrio ettai@ ir672.0011. Thc dacrcquirdo mfl& l[Lhfsrrlio ollErln LEdELdb.68c.l hmr pcrroc,ladodag tfc tinc fcwi*iof iit{udlott!, /tsdtinr ql!&lr dlh m:q lalqir ud njnuidrs ltc &b nr.dEd, ad @Dldir! .nd Flolq thc olkrdoo of iafsauim
uso -RUs
OPER^ATING REPORT FOR
TELECOMMUNICANONS BORROWERS
rbu tlll blsdb7 RUSmala'yorrfiaaclottluloe l-NBIWc k tq{bdbt7 US.C,90l ct tq,
Inlard TeleFhone Company
(Prepared wLth Audit.ed Data)
Efin o LlJS $lriln 30 doyr du cluc olthc Ftid.
dcloiled llttn6tlou, tcc RUS Bullctin I 741-1. Rcprt ia thok ddlon only.
. CERNFICANON
lfc hcrcby ceaifi' tlrot the eiltri.t lil lhb t€pott an ir affinldtce vitl, lhc dctourrg and othcr rccotds olthe sysrem an.t ftllec! the statl,6 of ,he ,isl.n
to the bast of our browlzdgc ud blief.
ALL INSURANCE EEQUIRED BY 7 CFR PANT I78& CHAPTER XVII, RUS, WAS IN TORCE DURING T}IE REPORTING PERIOD AND
RENEWAI,S HAVE BEEN OBTAINED FOR ALL POLICIES.
DURING THE P[:RIOI' COVERED BY 'I'HIS RXPOKT PURTiUAN'I"I'O PARI' ITOU OI'7C!R CHAI'TER XVII
(ClEcl om ol ,lE loflowbE)
E AI olthr obfigstons lrrdrr lh6 RUS loan dffimt!i8E bm tulllllcd h i[ materisl Epocls.E ThrE ha bean a dchu{ h hE fulil&rot of th8 sblte{oncBdu fic RUS loen dMmE, Sald drfadt(s) b/tr8
spocfllca[y dBglbod h ths Tdcom Op@thg Repod
304, 5rr0
160, 001
5. lntar€st and Dividends RsDalvabl€1, 991,871
259,636
641 ,t96
534,368
2, 139, 05 7- ,372 ,73
1_78,12 | , 096 ,122
1.300,634 808.121
TOTAL LIABIUnES AND EQUITY (3s+40+50+58)
4. Non AftlbtB3:
lhru 21 h3!
TOTAL ASSETS (1rFr7+231
Totel Equlty = 611 . 36* % of Total AEEats Page I ol I
USDA.RUS
OPERATING REPORT FOR
TELECOMMUNICATIONS BORROWERS
SORROWER DESIGNATION
t{40534
,ERIOD ENDING
Decariber, 2012NSIRUCI/ONS- See RUS Bullatln 17442
PART B. STATEMENTS OF INGOME AND RETAINED EARNINGS OR MARGINS
lTEM PRIORYEAR THIS YEAR
1. Local NetworkServlcesRevenuas 805, 031 713.304
2. Notwork Access Sarv'xxs Ftsvenues 4. 913,169 4,720,A23
3. Lono DislEne,s Netwo* SeMcBs Revanugs 1,79 18.094
4. Csnier Billlng and Collecuon Revenuas 53, 064 {9, 011
5. MlscellaneousRavenuas 93,495 LOg t 474
8. UncollecUbleRevenues t7 , o44 4,196
7. ilot Oporadnq RevBnues (1 thru 5 less 6l 5 , 8s7, 8911 5,605,916
8. Plant Spectfrc Operalions fupense 2,236,474 2,240,Ozt
9. Plant Nonspedllc Operalions Expense (Excludinq Depreclatlon & AmortlzaUon)170.469 338,850
10. Deorecialion Exoense 1.r1r.724 r,255,274
1. Amortization Expense 30, 911 LSt
2. CuslomerOoeralions ExDensE 443, I9L 517, 85r
3. Corporale Ooeratlons Exoanse 1, 150 , 148 1.032.59:
l{. Total Oooratlnq Erpsns$ (8 thru l3l s ,403 , 6L7 5,394,78''
5. Ooeratinq lnoome or Mamins (7 less 14)434,217 227. LzS
16, Olher OperaUnE lncome 8nd Exoonses
7. Slale and Local Taxes 1113,520 130. 333
16. Federal lncome Taxas 80, 881 99€
Olher Taxes
Total Tares (17+18+l!224 ,40L 131,33t
21. Net Operatinq lncome or Marqins (15+16-20)2?9 ,876 89. ?98
22 lntereston Funded Debt 117, 05rl 85, 114
23. lntergst ExDonse - Caoltial Leasss o
14. Other lnterest Bpense 10 14,555
15. Allowance for Funds Usod Durlnq Conslrucllon 0
16. Total Flred Chargier (U2+23+'12+251 !t7,074 )),/b!
17. NonoparatlnE Net lncome 2g . sL4 171r,535
18. Exlraordinary ltems 0
!9. Jurlsdictlonal Differencss 0
t0. NonrsEulatod Net lncome (49.316)(513, ?64)
tl. Tohl Net lncome or lrla]g,lns l2l+n+28+29+30-26)E2 - OOO l!4q- oqEl
12. Totgl Tsr(€s Based on lncome 47 , OL?(174.63e)
13. Retained Eamlnss or Mamins Beslnnino-of-Year 6-5{O_01?t - 6aa .4ae
14. Mlscellaneous Credlts Year-to-D€t6 2,449 1, 495
15. Dlvldoads Declared (Common)
36. Dlvldends Declared (Prcfened)
17. Olher Dablts Year-lo-Date
18. Transfers to Palronase Capllal 0
19. Retalnsd Eemlnge or Marglns End.o{-Porlod I(31+33+3{). (35+36+37+3811 6,634,4e6 5.286.88!
10. Pelronase Capltal BeslnninE-of-Year 0
1. Transfers to Patronase Capllal
12. Patronaoa Caoital Cr€dib Refired 0
E. Pabonase Capltd End.of.Y€er !t{l+,lt-{21 0
14. Annual D6bt SeMce Psym€nls 744 ,620 771,751
15. Cash Ratio l(14+20-1Gt 1) /0.7555 0.760(
iAccrual Rallo I 0.9807 1. 00].t
t7. T|ERI(31+20)/261 1.78s8 -2 .4991
t8. DSCRI(31+28+10+111 I 441 1.8959 1 ,401i
Page 2 of 6
uso -Fus
OPERATING REPORT FOR
TELECOMMUNICANONS BORROWERS
,IvSIRUCfrOlrS - Sso RUS Bulgilln 17t +2
EORROWER DESIGI.IATION
wAos34
PERIOD ENDED
Decemb€r,2012
Pert C- STjBSCRIBER TACCESS LINEL ROUTE MILE- & IIGII SPEED DATA INFORIIIATION
I- RATES r. nouTE lflLEs
E(CHANGE &1 R-1
thl
BUSIN€SS RESIDENTIAL
,hl
TOTAL TOTAL(indudlng Rber)lel
FIBER
,h\
,EWATTO ltN 2tLOl .l€w 3!t8 143.8[lLO1
]RFSCOTT 285t t4.50 38 l2a l6a 152 A7 t-0(
idsLYN ,L nl .t 3.80 174 I O,t!t.ta(t5r-ot :lt-oI
JNIOMT(IA'N 25 0I t5 0t lg2 tr!507 2'J1.8t la-{l(
FOhT 40.8t 2571 )!an 5 lto o0a
-ENORE .10.6E ,s7t ?2&t )7''177 N 12 rtt
irobneWirEles
RouE MIsEgeOrisld€ ErEhangr
0.0(0.0t
fotBl 442 2.059 2,50 e1a l,1(I1 t3
No. Exdranoe 6l
usoA-aus
OPERATING REPIORT FOR
TELECOMMUNICATIONS BORROWERS
,NSIFUC7IOTVS - S@ RUS Btl/Eltin 17t*2
BORROWER DESIGNATION
wA0534
PERIOO ENDED
Oecemb€r.2012
Part C. SUIISCRIBER {ACCESS IJNE}. ROUTE MILE- & mGH SPf,ED DATA INToIMATIoN
Det llr on Leet Ermmlm 3mrdblrd Errvle
EXCHANGE No. Acca$ Llns!
$,tlh BB
avrlable
No OfBroedb.nd
Subscrlberg
Number Of
Sub3cflbsrs
Adverttsad
Dournlosd Rele(ryff)
Advsr&€dUCed
Rsto (Kbps)
Prics Per lt onth
,n
Sbdalone/Pchg
,n
Type of
Technology
DEVUATTO 33I 22/tlI t8a il?taa3 PrcLe@ DSt
PRESCOTT t6I 51 5l TBA i7,1) AA ,aF.hda DSI
ROSLY.iI I la(7gr 712 rB O(tr}78tr 1? 8A ,aa,6aa nsl
JNIONTOWN 5{!7 zx t8q >B.Ollo ren It n3lP*ta6 DSt
EON 2t 1t 1d >a onn ,6R 26.08lPsckaoe DSI
.ENORF ,t!1^3 1t7 768 512 tg.T0lPeckaoe DSt
tnld 2 An1 t..l4t
OPERANilG REPORTFOR
TELECOMM UiIICANONS BORROYUERS
tst,tt'ruwEx uEstliNA I t(,N
I,IA0S3{
|-EI{IUU trNUINg
December, 2012
JSIFUCTTOTVS- Sao RUS Bld€An 171+2
PARTD. SYSIEHDATA
I . No. PfrrI EEdoFE lL Xo Ota Eoptoycrsl 43
, SSE& Mllq Sqvtd
453
,l.A6UEFSq@MIlc
s.40
,. SubEfrar !- Roulc Milc
2. gE
PART E TOLL DATA
sluoy Ar6E ru ${ro8(8,
".!:gb.522421
d.-
r.-
0.-
tr-
t-
t.
2. Typee of Toll SBulamont6 (ClEck one)
lnlerdda:
lntEslEla:
I averagesdrcdute
I evaaga Sdr€oute
[l coet aaai"
@ coaaasr
PART F. FUNDS IT{VESTED IN PLANT DURING YEAR
Rt S. RTB. & FFB L6en Funda Eroended 541,768
Olhaf Lono.Tem tien Funds ErDended
l. Funda Exosnded Under RUS lnlBrlm AoD(ov€l
l. Olher Short Tam loan FundE ErDMded
!96,772
22,2L7
Conlrlbution ln Aid
l. Grcss Addillong to Tde@m Planl (1 lhru 7)760 -1E7
PART G. lNVEElllEltTS llrl AFFIUATED COMPAI.IIES
IXVEST*IENTS
CUNNENT YEAIT DATA CUIIULATNE DATA
ht alrr€an
Thlr Ycar
ht
lncofiarL6s
n& Ylr
CunulEUE
lffiunl]Il
ToDds
,e,
Cmulallw
ln@ma/Lm
To Drta
CurErn
Brlsm
lnvsstrfiant h Amiabd Comosnl€B - Rursl DovEloomBrd 29O,61L 290,671 29O,671
lnvedmonl ln Aflniatsd ComDsnlrs - Nomral Developmsnl
Page 5 ol 6
USDA.BUS
OPERATING REPORT FOR
TELECOMMUNICATIONS BORROWERS
BORROWER DESIGNATION
9140534
PERIOD ENOING
Dac6nibe!, 2012
PART H. CURRENT DEPRECIATION RATES
Arc corporation's deprcciation rates approved by the rcgulalory authority
with jurisdioion over the provision of rlcphone rcrviccs? (Chcck onc)trI YES E]NO
EOUIPMEilT CATEGORY DEPRECIATION RATE
Land and supooil asseE - Motor Vehlcles 15. 00t
l. Land and supoort assets - Alrcraft
l. Land and suoportassets-Special puroosevehicles
Land and support assets - Garage and olher work equipment 15 .00*
i. Land End supoort asss6 - Bulldlnqs 4.00t
B. Land and suDoort assets - Fumlhre and Ofiice eaulpment 15.00t
/. Land and suDoort assets - General Du,Dose comout€rs 2s.00*
3. Central Oflice Switcilno - Dioitral 9.00t
l. Cenlral Office Switchlns - Analoa & Eleclro-mechanical
10. Central Office Switchino - OoeralorSvslems
1 1. Central Ofiice Transmission - Redio Svslems 13. Oot
12. Central Oftice Transmlssion - Circult eouloment 11.19t
13. lnbrmalion orisination/termination - Statlon apparatus
t4. lnfurmatlon orioinatlonltermination - Customer oremises wklno
I5. lnformauon originstion/termlnEtion - Lame prfuate branch exchanges
16. lnbrmaUon orlslnatiory'termlnailon - Public lelephone termingl equipment
I7. lnformatlon orlolnallnnlterminatlon - Other terminal eouioment
'8. Cable and - Poles 7 .59t
Cable and wira facililies - Aeria: cable - M6tal 42.06*
10. Cable and wire facilitles - Aerial cable - Flber 5.001
1. Cable and wire facilities - Undersround cable - Metal 6.00t
12. Cable and wlre f;acilities - Underground cable - Fiber 5.00t
23. Cable and wire facilities - Burled cable - Metral
!4. Cable and lvire f;acilltles - Burled cable - Fiber
15. Cable and wire facill[es - Conduit systems
16. Cable and wire facilities - Other
Page 6 of6
15.
j18.
17,Net
USDA4US
OPERATING REPORT FOR
TELECOMM UNICANONS BORROWERS
ln Notes
in Customer
In Lono Term Debt Cunent
BORROWER DESIGNATION
Il4053{
PERIOD ENDED
Decembar. 2012
INSTRUCTIONS - See help ln the online applicaUon.
PART I.STATEMENTOF GASH FLOWS
1.Beginnlng Cash (Cash and Equlvalents plus RUS Constructlon Fund)1.046.451
CASH FLOWS FROM OPERANNG ACTIVITIES
L Net lncome (3r19,0991
Adluslmenls to Reconclla Net lncofne lo Net Cash Prwldad by Operatlns Actlvitles
3. Add: Deoreclatlon L,255,214
1- Add: Amortlzatlon 182
5. Other (Explain)
See NotaB Page 387, 567
Chanoes ln Owafino Assets and Liabllities
6.Decrease/(lnqease) in Accrunts Receivable 199, 051
7.Decrease/(lncIease) ln Materials and lnventorv 96,96i
8.Decrease/(lncrease) ln Prepavmenls and Defened Charges (1,35S1
s.Decrease/(lncrease) in Other Gur.ent Assals 0
10.lncr€asey'(Dscr€asel ln Accouols Pavable (xl1,899)
11,Increase/(Decrease) in Advance Blllinos & Payments 0
12.lncrease/(Decrease) in Other Cunent LiablliUes 50, ?93
13.Nst Cash Provlded/lusedl bv Ooerallons 1.321.486
CASH FLOWS FROM FINANCING ACNVMES
14.Decrease/(lncrease) ln Notas Receivable 0
(15{,165)
555
lzLL.64el
18.lncrease/{Decrease) In Oihsr LlabiliUes & Defen€d Credats (91. s09)
19. Increase/(Decrease) in Caoltal Slock, Pald-ln Capital, Membershlp and Capilal Cedificales & Olher Capital 0
20.Less: Payment of Divldends 0
21.Less: Patmnaoe Capltal Credits Reured 0
22.Other (Explain)
See l{otss Page
898
23.Net Cash Provlded/(Used) by Flnanclng ActlvlUes (455, 85 9)
CASH FLOWS FROM INVESTING ACTWMES
24.Net Caoital Eroanditures (Prooertv. Plant & Eoulomentl (3s6,01s)
25_Other Lonq-Term lnvestmsnts (304,093)
26,Other Noncunent AsseE & Jurlsdlcdonal Differences 0
27. Olher (Explaln)
see tloeer Page (873,173)
28,ilet Cash Provldedl(llsedl bv lnveslino Actlvltles (1,533.281)
D.Net lncrEassl(Decreasel In Gash ({71,65{)
30. EndlnE Cash s74,79i
Revislon Date 2010
PART H-CURRENT DEPRECIATION RATES
rDAHO DEPRECTATTON RATES(WASHTNGTON RATES ARE ON PAGE 6)
Motor Vehicles-12.50%, Garage Work Equipment-L2.5O%, Other Work
Equipment-L2.50%, Buildings-2.50%, Furniture-15.00%, Company
Communications Equipment -5.O0%, General Purpose Computers -25.00%,
Office Support Equipment-5.00%, COE Switching-9.00%, COE
Transmission-Ll.l9?6, COE Radio-L3.OO%, Poles-5.00%, Aerial Cable-
4.A096, Buried Ca b le-4.00%, Fiber Optic-4.00%, Ae ria I Wi re-8.00%, rAeria I
Fiber-4.00%
PART.I STATEMENT OF CASH FTOWS
CASH FLOW RECONCITING EXPTANATIONS
Description Amount
Line 5 Other
Depreciation and amortization on non-regulated investments
Change in other taxes
Change in deposits
Cash surrender value of life insurance
Gain on sale of property
Deferred and state income taxes
Federal and state income taxes payable
Non-cash stock dividend
Total Amount of Adjustment
Line 22 Other
Reclassify change in deferred credits to operating activities
Reclassifo deposit change to operating activities
Total Amount of Adjustment
Line 27 Other
Remove retirements from line 24
Salvage
Additional amounts of long-term investments
Total Amount of Adjustment
74,448
(87,4421
566
{6,t471
122,2L7l.
(174,658)
(20)
(813)
(210,283)
Reclassify advances from affiliated companies change to investing activities LzO,75O
91,509
(s661
211,693
1404,7421
22,217
(103,593)
{486,118}
Page 1
4',l 2423<010> Studv Area Code
IN]TAND TEL'ID<015> Studv Area Name
2014<020> Proeram Year
<030> Contact Name: Person USAC should contact
with questions about this data
,James K. Brooks
<035> Contact Telephone Number: \soel 64e-22;-1Number ot the Derson identitied in data line <030>
<039> Contact Email Address: jbrookE@inledner . con
Email otthe oerson identitied in data line <030>
<100>
<200>
<zLO>
<300>
<310>
<320>
<330>
Service Quality lmprovement Reporting
Outage Reporting (voice)
Unfulfilled Service Requests (voice)
Detail on AttemPts (voice)
Unfulfilled Service Requests (broadband)
Detail on Attempts (broadband)
Fixed
Mobile
(compl ete o ft o ched worksh eel)
( com p I ete o ft o c h ed w otksh eet)
lcheck box when complete)r=-iEE
l_!_11 1 ,_J
ll-/-llE
I ll<- check box if no outages to report ffi
ll-/-I / I<400> Number of Complaints per 1,000 customers (voice)
<410> Fixed l-." I
<430> Number of Complaints per 1,000 customers (broadband)
0
I I bttuch descripilve docunentl
( o fto.h desc i p ti v e doc u n e ntl
(check to indicote certilicotion)
( oft o ch e d descti ptiv e d o c um e n t)
(che.k to indi.ote cdtilicotion)
( otoch ed desc ri ptive doc u n en t)
( com pl ete oft dch ed w o tksh eet)
( com pl ete o fr och ed w orks h eet)
( com p I ete oft dch ed w o tk sh eet)
(iI yes, complete otto.hed worksheet)
(check to indicote cettilicotion)
( o tta ch d es ct i pti ve d o cu m en t)
(iJ not, check to indicote cettilicotion)
( c o m pl ete dft o ch ed wotk sh eet)
( c om pl ete aft a.h ed w o tk sh eet)
<440>
<450>
<500> Service Quality Standards & Consumer Protection Rules compliance
.SfOr@
<500> Functionality in Emergency Situations
<610>-
<700> Company Price Offerings (voice)
<710> Company Price Offerings (broadband)
<800> Operating Companies and Affiliates \<900> Tribal Land Offerings (Y/N)? \J
<1000> Voice Services Rate Comparability.tororF ^ A<1100> Terrestrial Backhaul (Y/N)? (9 U
<1 110>
<1200> Terms and Condition for Lifeline Customers
<2000>
<2005>
<3000>
<3005>
Price Cap Carriers, Proceed to
lncluding Rote-of-Return Corriers offilioted with Price cop Locol Exchonge Corriers
(check to indicote cettificotion)
(com pl ete o ft o ched wo.k sh e et)
lcheck to indicote certificotion)
( com pl ete o tto c h e d w o tks h eet)
Rate of Return Carriers, Proceed to
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<o1o> study Area code 47242f
<015> StudyArea Name rN]]N TEL-rD
<020> Prosram Year 2014
<O3o> contactName-PersonU5ACshouldcontactrecardincthisdata James K' Brooks
<035> ContactTelephoneNumber-Numberofpersonidentifiedindataline<O3O> l5o9) 549-2277
<039> contactEmailAddress-EmailAddressofpersonidentifiedindataline<o3o> jblooks@inrandnet'com
TO BE COMPLETED BY THE REPORTING CARRIER, IF THE REPORTING CARRIER IS FILING ANNUAL REPORTING ON ITS OWN BEHATF:
Certification of Officer as to the Accuracy of the Data Reported for the Annual Reporting for CAF or Ll Recipients
certlfy that I am an officer ol the r€portint carrier; my responsibillties include ensuring the accuracy of the annual reportint requirements for universal *ruic! support
ecipients; and, to the b€st of my knowledg€, the information reported on this form and in any attachments is accurate.
{ame of Reoortine carrier: TNLAND TEL-rD
;ignature of Authorized officer: CERTTFTED omrm Date
,rintedhameof Authorizedofficer: Glegoly A' Maras
'itle or of Authorired Officpr recreLdtY
rhone numberof Authorizedoff;cer: (509) 549-221r
;tudy Area Code of Reporting carrier: 412423 Filing Due Date for this form: r0/15/20L3
underTitle 18 ofthe United states Code, 18 U.S.C. S 1001.
10110Do13 Page 72
472423<010> StudvArea Code
<015> StudvArea Name INI,AND TEL-ID
<020> Prolram Year 20t4
<030> contactName_personusAcshouldcontactreEardinEthisdata Jameg K. Brooks
<035> ContactTelephoneNumber-Numberofpersonidentifiedindataline<O3O> 1509) 649-22fL
Certification of Officer to Authorize an Agent to File Annual Reports for CAF or Ll Recipients on Behalf of Reporting Cariel
ca.tlty lh.t (t{are of Agontl lr authodad to rubfirt th. lnlomdon Eported on bsh.ll o, th. rrporong c.rier. I
rgont; and, to the best of my knowladgo, the Eports and data provlded to lhe rulhodEd agent i3 accunt3.
lame ofAuthorized
lameofReDortin€Carrier: INLAND TEIJ-ID
iitnature of Authorized Officer: CERTIFIBD ONLINE Date:
rrintcd name ofAuthorized Office.:
'itle or .ofA I offic.r:
bleohone number of Authorized Offic!r;
'tudv Area Code of Rewrtinacrrier 472423 Filinr Due Date for thistotmi 1o / Ls /2073
Persons willtully maling fale statements oh this fom can be punished by tine or forfeiture uhder the Communicationi Act of 1934, 47 U.S.C. 55 502, 503(b), or tine or imprisonment
underTitle 18 ofthe United States Code, 18 U.S.C. 5 1001.
<039> Contact Email Address - Email Addrrss of person identified in data line <030>jbrooks@inland[ec. com
TO BE COMPTETED 8Y THE REPORTING CARRIE& IF AN AGENT IS FITING ANNUAL REPORTS ON THE CARRIER'S BEHATF:
TO BE COMPTETED BY THE AUTHORIZED AGENT:
Certification of Agent Authorized to File Annual Reports for CAF or Ll Recipients on Behalf of Reporting Carrier
fie data rcported hercln based on data prevlded by the repo.ting 6niei; .nd, to the best of my knowledge, the lnformadon reported herein k .dBte.
{ame of Reporting Carrier:INI,AND TEL-ID
tlame of i Ac.nt dr Em6ldvr. ofAcent:
iiqnature of Authorized AEeht or Emolov.. of Arent: CERTTFTED OIIIJINE Datei
'rinted name ofAuthorizrd AEcnt or Emolovee ofArent
'itle or position ofAuthorized Arent or Employee of Agent
Gleohone number ofI I As.nt ofA.ent:
;tudv Area Code of Re@rting Carrier: 412423 Filins Du. Date for this form: to /7s / 2073
18 ofthe United States Code, 18 U.S.C. 5 1001.
1011012013
Page 13
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INLAND TELEPHONE COMPANT
lO3 S. 2ND Street
P.O. Box 171
Roslyn, WA 98941
(s0gl 649-22Lt; (8OOl a62-4s78
Fax [phone]
CERTIFICATION BY CUSTOMER IN ORDERTO RECEIVE FEDERAL LIFELINE SUPPORT
STATE ELIGIBILITY (Subscriber signature not required)
I certify that I am qualified through the:
Community Action Partnership Association of ldaho (CAPAI) (See email confirmation)
Washington Department of Social and Health Services (DSHS) - Case #
INCOME ELIGIBILITY
I certify that my household income is at or below L35% of the federal poverty guidelines and therefore I qualify for Lifeline Support
under the federal income requirements and have provided proof of my qualifications.
FEDERAL ELIGIBILITY
I certify that I qualify for Lifeline Support and am currently participating in one or more of the programs listed that I have checked below and am
providing a copy of my benefit or program participation card or award letter.
EE
E Supplemental Nutrition Assistance Program
tr]
E
Federal Public Housing Assistance (FPHA) or
Section 8
(SNAP)(Food Stamps)
Low lncome Home Energy Assistance Program
(LIHEAP)
National School Lunch Program's free lunch program
Federal Public Housing Assistance (FPHA) or
Section 8
Medicaid
Temporary Assistance for Needy Families (TANF)
E
E
fI
EEtl
Bureau of lndian Affairs General Assistance
Tribal Administered Temporary Assistance for Needy Families
(TTANF)
Temporary Assistance for Needy Families (TANF)
Food Distribution Program on lndian Reservations
Supplemental Security lncome (SSl)
lncome Eligibility (See lncome Eligibility)
E
E
E
EEE
SUBSCRIBER CERTIFICATION
It is understood that by participating in the Lifeline program, the support that I receive is not actual payment to me but a discount on my monthly
billed service. Participating in Lifeline does not protect me from collection procedures if I do not pay my phone bill. I fully understand that this
discount, as well as the criteria for participation in the Lifeline Program, may change and I may no longer qualify, or the amount of support may
increase or decrease.
E Supplemental Security lncome (SSl)
TRIBAL LIFELINE ELIGIBILITY Tribal ldentification Number
I certify that I qualify for tribal Lifeline Support, as I reside on land that meets the Bureau of lndian Affairs definition of "reservation" (any federally
recognized lndian tribe's reservation, Pueblo, or Colony including former reservations in Oklahoma, Alaska Native regions, and lndian Allotments)
AND participate in one or more of the programs listed that I have checked below and am providing a copy of my benefit or program participation
card or award letter.
f] Supplemental Nutrition Assistance Program
(SNAP)(Food Stamps)
Low lncome Home Energy Assistance Program
(LTHEAP)
National School Lunch Program's free lunch program
Head Start (lncome elieible)
Medicaid
Filename: 130808 APPLICATION - BY EXCHANGE.xIsx LIFELINE CERTIFICATION Page 1 of 3
As the Certifying Subscriber, I certify that, (i) the service is for me and not a member of the household; (ii) I am not listed as a dependent on
someone else's tax return; and, (iii) the service address is my prlmary residence. I further certify that the service that I receive from lnland
Telephone Company is my main line of service and neither I nor anyone in my household receives Lifeline Support for any other
telecommunications service. Further, I understand that Lifeline is a federal benefit program that provides a monthly discount on either home or
mobile telephone service and ONLY ONE Lifeline discount is allowed per household. Members of a household are not permitted to receive Lifeline
Supportfrommultipletelecommunicationscompanies. lunderstandthatviolationoftheone-per-householdrequirementwill resultinde-
enrollment from the program and possible fines and imprisonment. As the Certifying Subscriber claiming income eligibility, I certify that the
documentation I have provided accurately represents: (i) my household income and the number of persons in my household; or, (ii) proof of
participation in an eligible program.
I certify that I will notify lnland Telephone Company within 30 days,(i) if for any reason I should no longer participate in any of the eligible programs or qualify
byincome,andor(ii) if lmovefromtheaddressprovidedonthisform. lfmyaddresslistedaboveistemporary, lcertifythatlwillverifymyaddresstolnland
TelephoneCompanyevery90days. lunderstandthatiflfailtorespondtoanattempttoverifymyaddresswithin30days,myLifelinesupportmaybe
terminated. lunderstandthataflfail togivenoticeasrequired, lamsubjecttopenalties,includingde-enrollment,beingbarredfromtheprogramandfines
and imprisonment.
I understand that Lifeline Support is not transferrable and that I may not transfer my service to any individual, including another eligible Lifeline Support
recipient. I further understand that if my service goes unused for 60 days, my service will be suspended subject to a 30 day period in which I may use the
service or contact lnland Telephone Company to confirm that I want to continue receiving the service.
Further, I fully understand that in order to continue to receive this support, I must annually, or more often, certify my eligibility and provide proof of eligibility.
I understand that my failure to timely re-certify will result in de-enrollment and termination of my Lifeline benefits.
I fully understand that the Lifeline Program is administered by the Universal Service Administration Company (USAC) under the guidance and
authority of the Federal Communications Commission (FCC)and that all of the information that I have supplied pertaining to my eligibility will be
shared with USAC and the FCC and I give my consent to do so.
I certify that the information provided on this form is true and correct to the best of my knowledge under penalty of perjury and if I have provded
any misleading statements in order to receive support, I will be liable for any support received, my service may be discontinued, it may result in de-
enrollment and my being barred from the program and I would be subject to state and federalfines and imprisonment.
SIGNATURE OF APPLICANT
APPLICANT (PRINTED}
SOCIALSECURITY NUMBER
SERVICE ADDRESS
DATE
xxx-xx-DATE OF BIRTH
BILLING ADDRESS
TELEPHONE NUMBER NUMBER OF PERSONS IN FAMILY OR HOUSEHOLD
lnland Telephone Company will keep the information contained in this form confidential, except as required by federal or state law. Att INFORMATION
COMPLETED ON THIS TORM IS SUBJECT TO STATE AND FEDERAI. PERJURY PENALTIES.
nland TelephoneEE
E]
Company service - Customers serving Exchange
DEWATTO, WA
PRESCOTT, WA
ROSLYN, WA
EtlE
UNIONTOWN, WA
LENORE, ID
LEON, ID
TURE OF CUSTOMER SERVICE REPRESENTATIVE
NAME OF CUSTOMER SERVICE REPRESENTATIVE
Faderol o list of occeptoble dxum.ntotl@ fu lncffi.
Filename: 130808 APPLICATION - BY EXCHANGE.x|sx LIFELINE CERTIFICATION Page 2 of 3
I NLAND TELEPHONE COMPAT,IY
(5091 649-22LL; lsool a62-4s78
Fax [phone]
LIFELINE HOUSEHOLD WORKSHEET
Your household is everyone who lives together at your address as one economic unit (including children and people who are not related to you).
Theadultsyoulivewitharepartofyoureconomicunitiftheycontributetoandshareintheincomeandexpensesofthehousehold. Anadultis
any person 18 years of age or older, or an emancipated minor (a person under age 18 who is legally considered to be an adult). Household
expenses include food, health care expenses (such as medical bills) and the cost of renting or paying a mortgage on your place of residence (a
houseorapartment,forexample) andutilities(includingwater,heatandelectricity). Incomeincludessalary,publicassistancebenefits,social
security payments, pensions, unemployment compensation, veteran's benefits, inheritances, alimony, child support payments, worker's
compensation benefits, gifts, and lottery winnings
Spousesanddomesticpartnersareconsideredtobepartofthesamehousehold. Childrenundertheageof 18 livingwiththeirparentsor
guardiansareconsideredtobepartofthesamehouseholdastheirparentsorguardians. lfanadulthasnoincome,orminimal income,andlives
with someone who provides financial support to that adult, both people are considered part ofthe same household.
You have been osked to complete this Worksheet becouse someone else currently receives o Lileline-supported service at your oddress. This
other percon mdy or mdy not be o port oI yout household, Answer the questions helow to determine whether there is more thdn one
household residing ot your oddress.
1) Does your spouse or domestic partner (that is, someone you are married to or in a relationship with) already receive a Lifeline-discounted
phone? (check NO ifyou do not have a spouse or partner)' [-'lvrs E*o
> lf you checked YES, you may not sign up for Lifeline because someone in your household already receives Lifeline. Only ONE Lifeline discount is
allowed per household.
> lf you checked NO, please answer question #2.
Other than a spouse or partner, do other adults (people over the age of 18 or emancipated minors) live with you at your address?
EEE
Ivrs E*o
E*o
> lf you checked NO for each statement above, you do not need to answer the remaining questions. Please initial line B, below, and sign and date the
worksheet.
> lf you checked YES, please answer question #3.
Do you share living expenses (bills, food, etc.) and share income (either your income, the other person's income or both incomes
together) with at least one ofthe adults listed above in question #2?
!vrs E*o
>lfyoucheckedNO,thenyouraddressincludesmorethanonehousehold. Pleaseinitial linesAandBbelow,andsignanddatetheworksheet.
> lf you checked YES, then your address includes only one household. You may not sign up for Lifeline because someone in your household already
receives Lifeline.
CERTIFICATION
Please initiol the certificotion below ond sign and dote this worksheet which must occompony your Lileline applicotion.
A. I certify that I live dt dn address occupied by multiple households.
B. _ / understand that violotion of the one-per-household requirement is dgainst the Federol Communications Commission's rules and may
result in me losing my Lifeline beneJits, and potentially, prosecution by the United Stotes Government.
SIGNATURE
2l
A. A parent
B. An adult son or daughter
c. Another adult relative (such as a sibling, aunt,
cousin, grandparent, grandchild, etc..)
D. An adult roommate
E.
flves
!ves
NO
NO
NO
Other
3)
Filename: 130808 APPLICATION - BY EXCHANGE.xIsx LIFELINE CERTIFICATION
DATE
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