20140131Budget PrePay Form 555.pdf

FCC Form 555
December 2013
Approved by OMB
3060-0819
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: fanuory 31't (Annually)
State
(An Eligible Telecommunications Canier (ETC) nust provide a certiJicationform for each state in which it provides Ldeline service).
479016 Budget PrePay Inc.
Study Area Code(s) (SAC)ETC Name(s)
Budget Mobile
Holding Company Name(s)DBA, Marketing or Other Branding Name(s)
ETCs (include names and SACs, attach
ional sheets if necessary)
Provide a list of all ETCs that are afiliatedwith the reporting ETC. Affiliation shall be determined in accordance vith section 3(2) of the
Communications Act. That Section defines "afiiliate" as "a percon that (directly or indirectly) owns or controls, is owned or controlled by, or is
under common ownership or control with, another person." 47 U.S.C. S 153(2). See also 47 C.F.R. S 76.1200.
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 parhership 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:l// ETC; MUST COMPLETE SECTION I-Initial Certilication
I certiff 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 Lifeline
progrzrm, 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 progr:rm.
I am an officer of the company named above. I am authorized to make this certification for the Study Area(s)
listed above. Initial DD
ID
FCC Form 555
December 2013
Section 2: All ETCs MUST COMPLETE SECTION 2-Annual Recertification
Do nol leave empty columns. If an ETC has nothing to report in a column, enler a zero.
Approved by OMB
3060-0819
A B c
Number of
Subscribers Claimed on
February FCC Form(s) 497
ofcurrent Form 555
calendar year
Number of Lines Claimed on
February FCC Form(s) 497
ofcurrent Form555
calendar year provlded to
Wireline Resellers
Number of Subscribers claimed
otr tbe Fcbruary FCC Form(s)
497 thet werc ioitially enrolled ir
curre[t Form 555 calendar year
0 0 0
Inilial the certifications belov that apply to your E'I'C and complete lhe tables corresponding to the certification below. Depending on
the sqate, BOTH CERTIF]CATION A AND B MAY APPLY.
A) I certifr that the company 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 H=(F+G)I
Number of
Subscribers ETC
Contacted Directly
to Recertify
Eligibility Through
Attestation
Number of
Subscriben
Responding to
ETC Contact
Number ofNon-
Responding
Subscribers
Number of
Subscribers
Responding That
They Are No
LongerEligible
Number of Subscribers
De.enrolled or
Scheduled to be De-
Enrolled as a Result of
Non-Response or
Inclipibilitv
Number of
Subscribers Who
De-Enrolled Prior
to Recertilication
Attempt
0 0 0 0 0 0
AND/OR
In the space belov,, please list the program eligibility data sources, such as ETC access to a stale database and/or notice ofeligibility
from the state Lifeline administrator or the Universal Service Administrative Company ASAC) and indicate for which qualifying
programs(e.g.,SNAP,SSI)thesesourcesareusedloverfusubscribereligibility. I/anyofsubscribersaresubsequentlycontacled
directly by the ETC in ail attempt to recertify eligibility, those subscribers should be lisled in columns D through I as appropriate and
not in columns J tltrough L.
B) I certifr that the company listed above has procedures in place to re-certifr consumer eligibility by relying on
. Results are
provided in the chart below. I am an officer ofthe company named above. I am authorized to make this
certification for the Study Area(s) listed above. Initial _
J K L
Number of Subscribers
Whose Eligibility was
Reviewed By State
Administretor
ETC Access to Eligibility
Data or bv USAC
Number of
Subscribers De-Enrolled or
Scheduled to be Dc-Enrolled as a
Result of Finding of Ineligibility by
State Administrator, ETC Access to
Elieibilitv Data or USAC
Number of Subscribcrs Who
De-Enrolled Prior to
Reccrtification Attempt
0 0 0
OR
C) I certify that my company did not claim federal low income support for any Lifeline subscribers for the February Form
497 data month for the crxrent Fonn 555 calendar year. I am an offrcer of the company named above. I am authorized
to make this certification for the Study Area(s) listed above. Initial DD
FCC Form 555
December 2013
Section 3: ALL ETCS MUST COMPLETE SECTION 3 -De-enroll percentage
lYhat is the percentage of subscribers de-enrolledfor this ETC?
Approved by OMB
3060-08 r 9
M N o P=N+O Q=((P-M)* loo)
Number of
Subscribers Claimed
on February FCC
Form(s) 497
(From Colamn A)
Number ofSubccribers
De- Enrolled or
Scheduled to be De
Eorolled es a Result of
Non-Response or
Ineligibility
(From Column H)
Number of Subscribers
De Errolled or
Scheduled to be De-
Enrolled as a Result of
a Findirg of Iueli gibility
(From Colwtn K)
Total Number of
Subscribers De-f, nrolled
or Scheduled to be De-E
nrolled
Percenlage of Subscribers
De.Enrolled or Scheduled tt
be De-Enrolled thet were
Claimed on thc
February FCC Forn(s) 497
SECtion 4: ALL ETCS MUST COMPLETE APPROPRIATE CFIECK BOX; PRE-PAID ETCS MUST COMPLETE
ALL OF SECTION 4
Is the ETC Pre-Paid?
Yes Z No J (a fre-faid ETC does not assel,a or collect a monthlyfeefron its Lifeline subscribers)
If yes, record the number of subscribers de-enrolledfor non-usage by month in column S below.
Non-Usage Results Applicable to Pre-Poid ETCs:
R s
Month Subscrihers De-Enrolled for Non-Ilsape
January 0
Februarv 0
March 0
April 0
May 0
June 0
Julv 0
August 0
September 0
October 0
November 0
December 0
Sisnature Block: ALL ETCS MUST COMPLETE 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 ofthe company named above. I am authorized to make this certification for the Study Area(s)
listed above.
,3
Approved by OMB
3060-08r9FCC Form 555
December 2013
Sigred,
David Donahue DavidDonalrue
Signature of Officer
cFo
PrintedName of Officer
Jan-3 l-14
Title of Officer
Lakisha Taylor
Date
318-671-5736
Person Completing this Certification Forrn Contact Phone Number
FCC Form 555
December 2013
Approved by OMB
3060-0819
ETC ldentification
SAC ETC Name
479016 Budset PrePav Inc.
or Other Brandin
FCC Form 555
December 2013
Approved by OMB
3060-08 I 9
AffiIiAtCd ETCS
SAC Name