20140130Columbine-Silver Star Form 555.pdf

ID
472295
FCC Form 555
December 2013
Annurl Lifeline Eligible Telecsmmurications Carrier Cerlification Form
All eaniers must complete all or portions of all sections
Form mus: be submitted to USAC and filed with the Federal Communicalions Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIR$T
Deudline: Januory 3Id (Anaually) ',
State
lAa EtigibteTelecommruications Carrier {ETC) must prtvide a eenilieltion{onnfar each s&te in which it pravidx Lifeline se*icef,;a;
Columbine Telephone Co. lnc., Silver Star
Teleohone Co. lnc.
Study Area Code(s) (SAC)
Horizon Cornmunications, lnc.
Holding Company Name(s)D3A, Marketing or Other Branding Name(s)
Affiliated ETCs (inelnde names ancl SACs, altsch -Sse Attached Sheet-additianal sheets
Pro'$de a list of all ETCs that dre alliliated wirh the reporting ETC. Alfilituion shall be determined in accordanee with section j(2) of rhe
Camn unications Act. That Section defines "afiliate" as "a person lhat (directty rtr inrtircctllt owns or contrals, is oxmrll or contolled by, or
is under comman ownership or antral with, nother person." 47 U.S.C, ,l{ 153{2). See also 47 C.F.R ;\ 76. 1240.
For purposes of this filing an oflicer is an occupant of a position listed in the a*icle 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 agreernent), and rvould typically be president, vice president for operations, vice president for
finance, comptrotler, treasurer, or a comparable position. If the filer is a sole proprietorship, the owner must sign the
certification
Section l: All ETCI NUST COMPLETE SECTION I* Iaitial Certifie*ian
I certify that the compary listed above has certification procedu:es in place either to:
A) Revierv income and program-based eligibility documentation prior to enrolling a consumer in the Lifeline
program, and that, to the best of my knowledge, the compary was presented with documentalion of each
corsumer's houschold income andlor program-based eligibility prior 1o his or her enrollment in Lifeline or
B) Confirm consumer eligibility by relying upon access to a stste database and/or notice of eligibility from the
state Lifeiine 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 Study Area(s)
Approved by OMB
3060-08 r9
t-',"i
ETC Name(s)
Silver Star Communications
listed above. Initial
Approved by OMB
3060-08 I 9FCC Form 555
December 2013
Section 2: All ETCr MUST COMPLEZE SECTION 2- Anxual ReceaiSution
Do not leave empty columns. If an ETC has nothing to report in a columa, enter 4 zero.
A B c
l{umbcr of
Sulxcrlbcru Chlmcd ou
Frbrnrry FCC Forr{r} d9?
of.rrrcot Form 355
trltldrr ycrr
Numbrr of Liner Clelmtd or
Fcbrurry FCC Forrdr) 49?
ofcurrtrt Fonn 155
lrtcadrrycrr providrd to
lYirclire Rcrllkrs
Nrmbrr of Substribcrs cklmcd
ar lht Fcbrurry FCf Foratr)
{97 thtrvcr iritldly enrollttl ir
(urrrtrt form S55 crlcrdlr ycrr
44 0 e
Initial the certifcatiorc below that apply to y'our ETC attd complete thc tabl* coresponding ta the cet'tifcatian belo*. Depending
on the stdte. BOTTI CERTIFICATION I AND B MAY APPLY.
A) I certify ihat the company lisled above has procedures in place to recertify the continsed 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
Stud listed above.
;ffiS#oypy named above. I am authodzed to make this certification for the Study Area(s
D tt F=D-E C H = (r+c)
Nrmbcr of
Srhccribers ETC
Conirctcd Dircctly
:o Rcccrtify
Eligibility Through
Aatcalation
Numbcr of
Sulxcribcrs
Rcsponding to
ETC Contacl
Numbcr of llo*-
Rcsponding
Subscribcrs
Ittmbcr of
5rlb6ctib.x
Rerpondiag Thal
Thcy Are No
Longcr Eligible
Numbcr of Suhrcribers
Dc-cnrollcd or
Schedulcd to bc Dc-
Enrolled a* r Result of
Non-Ilc*ponsc or
Inclioihilltv
Number of
Subrcrihrrs lYho
Ile-Enrolled Prior
to Recrrtificrtion
Atlempl
8 2 6 0 5 0
ANDIOB
In the space below, please list the pragram eligibility data sources, $rch as ETC access ta a stote database and/or notice of
eligibiliry /rom the state Lifeline administrator a*he Universol Service Administrative Company (USAC), and inclicate for which
qualifying pragrams (e.g., SIflfl SSI) these sources are used to verifu subscriber eligibility. If any of subscribers are
subsequentlv contacted direclly by the ETC in an otternpt to recerti,fy eligibili{y, those subscribers should be listed in columns D
through I as appropriate and nat in columns J through L.
B) t ce*iry that the company listed above has procedures in place to re-certify consumer eligibility by relying on
wlarI!*ltyltsd.ComdtArrdPdir.lrrAe*.rlonoal&lu.b$*rffs.}fccio!rr$.r.s{e.&t {.d.rdr6o!&a!**fiaidir.td[hdp.i*l$]ffi.&ibiity . ReSUltS afg
ake this
certification for the Study Area(s) listed above. lnitiataff /
J K L
Numbcr of $:rbs*rib*rs
lt'bose Eligibiliry wes
Rwkwcd By Slrtc
Administr*tor
ETC Accc** to Eligibility
I)ate or bv I-ISAC
Numbcr of
Sub*eribrrs Dc-Enrolhd or
Sciedulrd to hc Dc-Enrollcd rs a
trcsult of Finding of Ineligibility by$t tc Ad&iaistratorl ETC Acccss t0
f,ttsibilitv Drie or USAC
l\umber of $rb*cribc:r Who
Dc-Enrolled Prior lo
Reeertifitalion Attrmpt
36 0
OR
C) I cerrify that my company did not claim federal low income support for any Lifeline subscribers for the February
Form t197 data month for the currenl Form 555 calendar year. I am an omcer of the company named above. I am
authorized to make this certification for the Study Area(si listed above. Initial _
Approved by OMB
3060-08 I 9FCC Form 555
December 2013
Section 3: ALL ETCS MUST COMPLETE SECTIOT( 3 - De-enroll percentage
What is lhe percentage of subscribers d*enrolledfor this ETC?
Section 4: ALL ETCS MUST COMPLETE APPROPRIATE CHECK BOX; PRE.PAID ETCS MUST
COMPLETE ALL O-T. SECTION 4
Is the ETC Pre-Paid?
to f] *o V (A Pre-Paid ETC does not assess or collecr a monthlyfeefron its Lifeline suhscribers)
If yes, record the number of wbscribers de-enrolledfor non-u.sage by month in column S below.
Non-Usage Results Applicable to Pre-Paid ETCs:
R s
Month Subscribers De-fnrolled for Non-lIsese
January
Februarv
March
Aoril
Mav
June
July
Ausust
Seotember
October
November
December
Sigcature Block: ALI. ETCS MUST COMPLETE SIGNATURE FIELDS
By signing below, I certify that the company listed above is in compliance rvith all federal Lifeline certification
procedures. I anr an officer of the company named above. I am authorized to make this certification for the Study
Area(s) listed above.
ilI N o P=li+O Q=((P*M)r 100)
Numbrr of
Subscrihrr Chincd
on Fcbrurry FCC
lbrm(s) {97
(From Column A)
Nurrber ofSubrcribcrs
Dc- Enroltcd or
Srhcdulcd to bc Dc-
Enrollcd rs r Rcsull of
Non-Rcrporrc or
Incligibllity
(From Column lb
Numbcr ofSubrcrlbcrr
Dc- Errollcd or
S.hcdElcd to bc llc-
Earollad ai r Rcrult of
r Finding of lncligibility
(From Column K)
Tot l Nurlbcrof
Srbscribcrs Dc-f, lrollcd
or Schtdulcd to b. Dc-E
nrollcd
Pcrc.ntrgc of Subrcribcrr
Dc-Enrolhd or Schcdulcd tr
bc Dc-Enrollcd thrt wcr?
Clrimcd oo tbc
Fcbrurry FCC Form(r) .197
M 6 0 b 14Yo
Approved by OMB
3060-0819FCC Form 555
December 2013
Title of Officer
Michelle Motzkus
Jefferson H. England
Printed Name of Officer
January 29,zAM
Date
307-883-6690
Contact Phone Number
ETC Identification
SAC ETC Name
47229,5 Columbine Tel€phone Co. lnc., Silver Slar Telephone Co. lnc
or Other Brandi
Approved by OMB
3060-08 I 9FCC Form 555
December 2013
Affiliated ETCs
SAC Name
519m1.512295 Silver Star Telephona Co., Inc.
479011.519005 Gold SlBr Communicatbns, LLC