20140128Fremont Telcom Form 555.pdf

&m#n;xr I l0 Eost Moin Street I St. Anthony,lD 83445
Business: 1208l, 624-7 000
Residentiol: '208l, 624-7 300
www.f rem ontsolufi ons.com
Lifeline He-Certification - FCC Form 555
January 17,2014
Community action Partnership Association of ldaho
5400 W. Franklin Road, Suite G
Boise, lD 83705
Re: WC Docket No. 11-42
Fremont Telcom Co. Respectfully submits the attached certifications pursuant to 47 CFR $54.416 (b)
and 54.410 (d) as required by the FCC's Lifeline Heform Order. The filing has been electronically in
accordance with the Commission's Public Notice DA 12-1626.
b NR-T- t4-o I
Sincerely,
''flit c,l*t[ U,, fue]<
Michelle Norbeck
Carrier & Regulatory Specialist
Fremont Telcom Co.
1221 N. RussellSt.
Missoula, MT 59808
cc: USAC High Cosl Low lncome Division
FCC Secretary
Approved by OMB
3060-08 I 9FCC Form 555
Decernber 2013
Annual Lifeline Eligible Telecommunications Carrier Certifi cation Form
All carriers must complete all or portions of all sections
Fonn must be submitted to USAC and filed wilh the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: lanuary 31't (Annually)
State
(An Eligible Telecotnmunications Catier (ETC) must provide a certificalionformfor each shte in u,hich it provides Lifeline service),
472222 Fremont Telcom Co.
ID
Study Area Code(s) (SAC)
Blackfoot Holdings, Inc.
ETC Name(s)
Fremont Communications
Holding Company Name(s)DBA, Marketing or Other Branding Name(s)
ffiliated ETCs (include names and SACs, attqch -See Attached Sheet-sheels
Provide a list of all ETCs tha! are afiliated with the reporting ETC. Afiliation shall be detennined in occordonce with section 3(2) of the
Communications Act. That Section deJines "qfiliate" as "a person lhat (directly or indirectly) owns or controls, is owned or controlled by, or is
undercommonownershiporconffolwith,anotherperson."47U.S.C.S153(2). Seealso47C.F.R.S76.1200.
For purposes of this filing, an officer 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. If the filer is a sole proprietorship, the owner must sign the
certification
Section l: All ETCs MaST COMPLETE SECTION 1- Initial Certijication
I certif, that the 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 Lif'eline
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 database 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 company named above. I am authorized to make this certification for the Shrdy Area(s)
listed above. Initial MA(
FCC Form 555
Decenrber 2013
Section 2: All ETCs MUST COMPLETE SECTION 2-Annual Recertification
Do ttot leave empty colttmns. I/ an ETC has nothing lo report in a column, enter a zero.
Approved by OMB
3060-08 l 9
A B C
Number of
Subscrlbers Clainrcd on
February FCC Fonn(s) 497
of current Form 555
calendrr year
Numbcr of Lines Clalmed on
February FCC Form(s) 497
ofcurrent Forn 555
crlendrr year provided to
Wlreline Rsellers
Nu mber of Subscribers claimed
on lhe February FCC Form(s)
497 that were initially enrolled ir
current Form 555 colendar year
l4l 0 l4l
Initial the certificatiotts below that apply to your ETC and complete the tables corresponding to the certil'ication belotv. Depending on
the state, BOTH CERTIFICATION A AND B IvAY APPLY.
A) I certiff that the cornpany listed above has procedures in place to recertifr 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 FI = (F+G)I
Number of
Subscribers E'I'C
Contacted Directly
to Recertify
Eligibility Through
Attestation
Number of
Subscribers
Responding to
ETC Contact
Number ofNon-
Responding
Subscribers
Number of
Subscribers
Responding That
They Are No
Longer Ellglble
Number of Subscribers
Derenrolled or
Scheduled to be De-
Enrolled as a Result of
Non-Response or
Inelisibilitv
Number of
Sutrscribers Who
De-Enrolled Prior
to Recertilication
Attempt
0 0 0 0 0 0
AND/OR
In the space below, please list the program eligibility dala sources, such as ETC access lo a slate database and/or notice ofeligibility
lrom lhe state Li/eline administrator or the Universal Sertice Administrative Company (USAC) and indicate for vvhich qualtfying
prograns (e.g., SNAP, SSI) these ,sources are used to verifi subscriber eligibility. If any of subscribers are subsequenlly contacted
directly by the ETC in an atternpt to recertify eligibility, those subscribers should be listed in columns D through I as appropriate and
not in columns J through L.
B) I certifr that the company listed above has procedures in place to re-certi$ consumer eligibility by relying on
lfdb.riEtrhri'&pn&EJb&*r.dl&fio6rcAIAr(mn!ilrAdiotrPledp^lsi:Gr.tl6bt. bLMk.[!do!or6f.Is6lqdrss{[e-mail]&hd..&rrcdr . 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. Initlal MAG
J K L
Number of Subscribers
Whose Eligibility was
Revieryed By State
Administrator
ETC Access to Eligibitity
Data or bv USAC
Number of
Subscribers De-Enrolled or
Scheduled to be De-Enrolled as a
Result of !'inding of Ineligibility by
State Administrator, ETC Access to
Elisibilitv Data or US.A,C
Number of Subscribers lVho
De-Enrolled Prior to
Recertification Attempt
I 304 42 0
OR
C) I certify that rny corllpany did not claim federal low income support for any Lifeline subscribers for the February Form
497 data month for the current Form 555 calendar year. I am an officer ofthe company named above. I am authorized
to make this certification for tlte Study Area(s) listed above. Initial _
FCC Form 555
December 2013
Section 3: ALL ETCS MUST COMPLETE SECTION 3 -De-enrollpercentage
lYhat is the percentage olsuhscribers de-enrolledfor this ETC?
Approved by OMB
3060-0819
M N o P=N+O Q=(p+tvt)*t[[)
Number of
Subscribers Claimed
on February FCC
Form(s) 497
(From Colunn,4)
Nurnber ofSubscribers
De- Enrolled or
Srheduled lo be De-
EnrolledmaResultof
Non-Response or
lneliglbility
(From Column H)
Number ofSubscrlbers
De- Enrolled or
Seheduled to be De-
Enrolled ss a Result of
a Finding of Ineliglbility
(Fron Column K)
Total Number of
Subrcribers De.Enrolled
or Scheduled to be De-E
nrolled
Percenlege of Subscrlbcrs
De-Enrolled or Scheduled t(
be De-Enrolled thlt lvere
Clalm€d on the
Februrrf FCC Form(s) 497
141 0 42 42 30o/o
Section 4: ALL ETCS MUST COMPLETE APPROPRIATE CHECK BOX; PRE-PAID ETCS MUST COMPLETE
ALL OF SECTION 4
Is the ETC Pre-Paid?
Yes I rya V @ fre-faid ETC does not assess or collect a nonth$,feefi'om its Lifeline subscribers)
If yes, record the number of subscribers de-enrolledfor non-usage by month in column S below.
Non-Usage Resalts Applicable to Pre-Paid ETCs:
R s
Month Subsrribers De-Enrolled for Non-Usaue
Januarv
Februarv
March
April
Mav
June
Julv
August
September
October
November
December
Siqnature Block: ALL ETCS MUST COWLETE SIGNATUfuE FIELDS
By signing 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.
Approvcd by OIvIB
3060-08r9FCCFomr 555
December 2013
Signed,
Marlys A Gillen
Sigaature of 0fficer
Manager, Revenue Accounting
Title of Officer
MichelleNorbeck
Ferson Completing this Certification Fonn
Printed Name of Officer
laul.-l7-14
Marlys A Gillen
Date
'mG54l-5131
Contact Phone Number
FCC Form 555
December 2013
Approved by OMB
3060-08 l 9
ETC Identification
SAC ETC Name
472222 Frenront Telcom Co.
Blackfoot Holdines. Inc
or Other Brandi
Fremont Communications
Approved by OMB
3060-08 I 9FCC Form 555
December 2013
Affiliated ETCs
SAC Name
482235 Blackfoot Telephone Cooperative Inc.
483308 Blackfoot Telephone Cooperative Inc.