20140121Direct Communications Rockland Form 555.pdf

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3060-08 19FCC Form 555
December 2013
Annual Lifeline Eligible Telecommunications Carrigr Certification Form
All carriers must complete all or portions'of atl sections
Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deodline: lanuary 3I't (Annualty)
_7L1,
State
(An Eligible Telecomtmtnications Can'ier (ETC) musl provide o cerlificationformfor each state in which it provides Ldeline semice).
47zztz P;"q-t G,.^** ;. }lar,c R^, [ )^r^ J
Study Area Code(s) (SAC)ETC Name(s)
Holding Company Name(s)DBA, Marketing or Other Branding Name(s)
Affiliated FiI'Cs (include na,nes and SACs, attach
add i t ional she ets if ne cessary)
Provide a list of all ETCs that are aJfiliatedwith the reporting ETC. Affiliation shall be derermined in accordance with section 3(21 of the
Communications ,4ct. That Section defines "afrliate" as "a person that (directllt or indirectly) owns or conlrols, is owned or conlrolled by, or
isttndercommonownershiporconlrol with,onotherperson."47U.S.C.5l53(2). Seealso47C.F.RS76.l200.
For pu'poses of this filing. an oflicer is an occupant of a position listed in the article of incorporation, articles of
formation, or other similar legal document. An officer is a person who occupies a position specified in the corporate
by-laws (or partnership agreement), and would typically be president, vice president for operations, vice president for
finance, comptroller, treasurer, or a comparable position. lf the filer is a sole proprietorship, the owner must sign the
certitication
Section l: All ETCs MUST COMPLETE SECTION l- Initial CertiJicution
I certifu that rhe company listed above has certification procedures in place either to:
A) Review income and program-based eligibility documentation prior to enrolling a consumer 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 or
B) Confirm consumer eligibility by relying upon access to a state dalabase and/or notice of eligibility from the
state Lifeline administrator prior to enrolling a consumer in the Lifeline program.
I am an officer of the flfrrqirny named above. I am authorized to make this certification for the Study Area(s)
listed above. Initial,1_)
t
Approved by OMB
3060-08 l 9FCC Form 555
Dcember 2013
Section 2: All ETCs MUST COMPLETE SECTION 2-Annuol Recerti/ication
Do nol leave empty columns. If an ETC has nothing to report in a column, enter q zero.
A B C
Numbcr of
Subscribers Clrimed on
Frbruary FCC Form(s) 497
ofcurrcnt Form 555
crlendar yerr
Number of Lincc Claimtd on
Februery FCC Form(s) 497
ofcurreut Forf,555
celendrr yeor providcd to
Wirclinc Rescllers
Numbcr of Subscribcrs cleimcd
on the Februrry FCC Form(s)
{97 thal were initially cnrollcd ir
eurrcnt F-orm 555 crlcndar ycar
Z'a L
Initial the certilications below that apply to your ETC and complete the tables corresponding to the certification below. Depending
on Ihe SIaTe, BOTH CERTIFICATION A AND B Iv*IY APPLY.
A) I certiff that the company listed above has procedures in place to recertify the continued eligibility of all of its
Lifeline subscribers, and that, to the best of my knowledge, the company obtained signed certifications from all
subscribers attesting to their continuing eligibility for Lifeline. 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 _
D E F =D-E G s = 1F+C)
Number of
Subscribers ETC
Contrcted Dircctly
to Recertiff
Eligibility Through
Attestation
Numbcr of
Subscribers
Responding to
ETC Contact
Number ofNon-
Respoading
Subscribers
Number of
Subscribers
Responding That
They Are No
Longer Eligiblc
Number ofSubscribers
De-enrolled or
Schedulcd to be De-
Enrolled as a Rcsult of
Non-Response or
Inclisibilitv
Number of
Subscribcrs r,r-ho
De-Enrolled Prior
to Recertifrcation
Attcmpt
AN\6fl)
In the space below, please list lhe prograot eligibility data sow'ces, such as ETC access to a slate database andtor notice of
eligibilityfiom the state Ldeline administrator or lhe Universal Service Administrative Company (USAC), and indicate for *hich
qualifying programs (e.g., SrVlP, SS{ these sowces are used to verify subsuiber eligibility. If any of subscribers are
subsequently contacted directly by the ETC in an attempt to recertifu eligibility, those subscribers should be listed in columns D
lhrough I as uppropriale and not in columns J through [..
B)I the listed above has re-certify eligibilify by relying on
. Results are
provided in the chart below. I am an officer of the c named above. I am authorized to make this
certification for the Study Area(s) listed above. Initial
OR
C) t certi! that my company did not claim federal low income support for any Lifeline subscribers for the February
Form 497 data rnonth for the current Form 555 calendar 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
-
Numbcr ofSubscribers
\['hosc Eligibilitv was
Revicwcd By Stete
Administrator
ETC rlccess to Eligibilitl
Drta or by USAC
Numbcr of
Subscribers De-f,nrollcd or
Schcduled to be Dc-Enrotled as r
Re$ult of Fioding of Ineligibility by
State Administrator, ETC Acc€ss to
Numbcr of Subscribers Who
De-Enrollcd Prior to
Recertification Atie mpt
Approved by OMB
3060-0819FCC Form 555
December 2013
Section 3: ALL ETCS MUST COMPLETE SECTION 3 - De-enroll percentage
What is the percentage of subscribers de-enrolledfor this ETC?
SCCtiOn 4: ALL ETCS MUST COMPLETE APPROPRIATE CHECK BOX; PRE.PAID ETCS MUST
COMPLETE ALL OF SECTION 4
Is the ETC Pre-Paid?
Yes [] l'a $ & fre-l'aid ETC does not assess or collect a monthlyfeefrom its Lifeline subscribers)
IJ yes, record the number o.f'subscribers de-enrolledfor non-usage by month in column S below.
Non-Usage Results Applicable to he-Psid ETC,:
R S
Month Suhscribers T)e-Enrolled for No:r-IIsase
January
Februarv
March
Aoril
Mav
June
July
Ausust
September
October
November
December
Siqnature Block:.4LL ETCS |,[UST COMPLETE SIGNATURE FIELDS
By signing below, I cenifu 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 malie this certification for the Study
Area(s) listed above.
t\t N o P=N+0 O=({P+l}I)r100)
Numbrr of
Subscribers Claimed
on Febru*ry FCC
Foro(r) 497
lFrom Colunm A)
Numbtr ofSubscrihcrs
De- f,nrolled or
Schedulcd lo be De-
Enrolled rs r Rlsult of
Non-Rcspotrse or
lneligibilit-v
(From Colunn H)
Numbcr of Subscribcrs
Dc- Enrollcd or
Scheduhd to be De-
f,nrollcd es a Rcsull of
a Finding of tneligibility
(l;rom Column K)
Totrl NuEbcr of
Subscribcrs De-Enrolled
or Scheduled lo bc Dc-E
nroll€d
Percrnlrgc of Subscribcrs
DeEnrolled or Scheduled tr
be De-Enrolled thet wcre
Clrimed on the
Februrry FCC Form(s) ,197
?t o t zg,8 v
FCC Form 555
December 2013
Approved by OMB
3060-08 l9
Signed,
Dateaa-*e-erdr
Person Completing this Certification Form Contact Phone Number
ETC Identification
SAC ETC Name
Marketi or Other Brandi
gnaturelf Officei
Title of Officer
hn * O/^l/
Printed Name of Ofhcer
Approved by OMB
3060-0819FCC Form 5-55
December 2013
Affiliated ETCs
SAC Name