20140130Rural Telephone Company Form 555.pdf

FCC Form 555
December 2013
Approved by OMB
3060-0819
Annu al Lifeline Eligible Telecommunications Carrier Certifi cation Form
All carriers must complete all orportions of all sections
Form must be submitted to USAC and filed with the Federal Communications Commirrioo
, ..,:,r ::::i
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST . .' . ,.,i ,,
Deadline: January 37't (Annually)
ldaho
State
(An Eligible Telecomtmrnications Catier (ETC) must provide a cenification formfor each state in which it provides Lifelin servi[$
472233 Rural Telephone Company
Study Area Code(s) (SAC)
Rural Telephone Company
Holding Cornpany Name(s)DBA, Marketing or Other Brauding Name(s)
Affiliated bTCs (include names and SACs, attach RTI Rural Telecomadditional sheets
Prcvide a list ol all ETCs that are afiliated with the reporting ETC. Afiliation shall be determined in accordance with seclion j Q) of the
Communications Act. That Section defines "affliate" as "a person that (directly or indirectly) owns or controls, is owned or controlled by, or
Ltundercommonotonershiporcontrolwith,anolherperson."4TU.S.C.li153(2). Seealso47C.F.R.!;76.1200.
For pulposes 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 parhrership 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 MUST COMPLETE SECTION l- Initial Certification
I certify that the coapany listed above has certification procedures in place eittrer to:
A) Review incoms and program-based eligibility docunentation prior to enrolling a consumer in the Lifeline
progranl 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 enrollrnent in Lifeline or
B) Confirrn 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 cgmpany named above. I am authorized to make this certification for the Study Area(s)
li sted above . lnttral.lfut
ETCName(s)
RTI RuralTelecom
Approved by OMB
3060-0819FCC Ilorm 555
December 2013
Section 2: All ETCs MUST COMPLETE SECTION 2-Annual Recertificafion
Do not leave empty columns. If an ETC has nothing to report in a column, enter a zeto.
A B C
Number of
Subscribers Clrlmed on
February FCC Form(s) 497
of current Form 555
calendar year
Number of Lines Clalmed on
February FCC Form(s) 497
ofcurrent Form555
calendar year provided to
Wireline Resellers
Nurnber of Subscribers claimed
on the February FCC Fonr{s)
497 that were lDldelty enrolled fu
cumert Form 555 calendaryear
12 0 U
Initial the certifications below that apply to your ETC and complete the tables conesponding to the certificotion below. Depending
on the state, BOTTI CERTIFICANON AAND B MAYAPPLY.
A) I cerlifr that the company listed above has procedures in place to recertiff the continusd eligibility of all of its
Lifeline subscribers, and that, to the best of my knowledge, the company obtained signed certifications frorn al1
subscribers attesting to their continuing eligibility for Lifeline. Results arc provided in the chart bclow. I am an
officer of the company named above. I am authorized to make this certification for the Study Area(s) listed above.rnitial!fl
D E F =D-E G H=G+C)I
Number of ,
Subscribers ETC
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 Eligible
Number of Subscribers
De-enrolled or
Scheduled to be De-
Enrolled as a Result of
Non-Response or
fnefipibilitv
Number of
Subscribers Who
De-Enrolled Prior
to Recertification
Attempi
11 0 I
AND/OR
In the space below, please list the program eligibility data sources, such as ETC access to a state database and/or notice of
eligibilityfrom the state Lifeline administrator or the Universal Service Administrative Company (USAC), and indicatefor which
qnalifying programs (e.g., SNAP, SSD these sources are used to verify subscriber eligibility. If any of subscribers are
,subsecluently contacted directly by the ETC in an attempt to recerlify eligibility, those subscribers should be listed in columns D
through I as appropriate and not in columns J through L.
B) I certify that the company listed above has procedures in place to re-certify consumer eligibitity by relying on
Notice from ldaho State lifeline Administrator Results arc
provided in the chart below. l am an officer of the company named above. I am authorized to make this
certification for the Study Area(s) listed above. Ininil 5fuq/
J K L
Number of Subscribers
Whose Eligibility was
Reyiewed By State
Administrator
ETC .dccess to Eligibility
Data or bv USAC
Number of
Subscribers De-Enrolled or
Scheduled to be De-Enrolled es a
Result of Finding of lneligibility by
State Administrator, ETC Access to
Elisibility Data or USAC
Number of Subscribers Who
De-Enrolled Prior to
Recertifi cation Atte mpt
12 0 1
OR
C) I certiff that my company 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 ofFlcer of the company named above. I am
authorized to make this certification for the Study Area(s) listed above. Initial _
Approvedby OMB
3060-0819FCC Form 555
December 2013
Section 3: ALL ETCS MUST COMPLETE SECTION i - De-enroll percentage
llhat is the percentage of subscribers de-enrolledfor this ETC?
SeCtion4: ALL ETCS MUST COMPLETE APPROPRIATE CHECK BOX; PRE-PAID ETCS MUST
COMPLETE ALL OF SECTION4
Is the ETC Pre-Paid?
,^ f] *, V (A Pre-Paid ETC does not assess or collect a ntonthly/befrom its Lifeline subscribers)
If yes, record the number of subscribers de-enrolledfor non-usage by month in column S below.
Non-Usage Results Applicablc to Pre-Paid ETCs:
R s
Month Snhserihers De-f,,nrolled for Nnn-f Isnqe
fanuary
Februarv
March
April
Mav
June
Julv
August
September
October
November
December
Sienature Block: ALL ETCS MUST COMPLETE SIGNATURE FIELDS
By signing below, I certiff 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 rnake this certification for the Study
Area(s) listed above.
M N o P=N+O O=/{P+MI*100)
Number of
Subscribers Claimed
on f,'ebruary FCC
Form(s) 497
(From ColumnA)
Number of Subscribers
De- Enrolled or
Scheiluled to be De-
Enrolled as e Result of
Non-Response or
Ireltglblllty
(From Column H)
Number ofSubscrlbers
De- Enrolled or
Scheduled to be De-
Eurolled as a Result of
a Finding of IneUglblfity
(Frou Coluntn K)
Totel Number of
Sobscribers De-Enrolled
or Scheduled to be De-E
nrolled
Percentage of Subscribers
De-Enrolled or Scheduled tt
be De-Enrolled thet w'ere
Clalmed on the
February FCC Eorm(s) 497
12 1 0 1 R-1
Approved by OMB
3060-0819FCC Forrn 555
December 2013
James Martell
Printed Name of Officer
0112712014
Title of Officer
Theresa Wilson
Date
208-366-2614
Person Completing this Certi{ication Form Contact Phone Number
ETC Identification
SAC Ti.'I'C Name
472233 Rural Telephone Company
DBA, Marketi or Other Brandi
fure
Approved by OMB
3060-0819FCC Form 555
December 2013
Affiliated ETCs
SAC Name