20140131Mud Lake Telephone Form 555.pdf

FCC Form 555
Deccmbcr 2013
Annm l Llfcllac Ell glblc Ttlcconr m unlcrtlons Ce rricr Ccrtillcet lon Form
All canicrs nlust complctc all or portions of all scctions
Form must be submitted to USAC nnd lilcd tvith thc Fedcrat Cornmunications Commission
IMPORTANT: PTEASE READ INSTRUCTIONS FIRST
.Dcodllnc: lu n aary 3 ltt (A nnaotltl
ldaho
Sutc
(1{n EtlgiMc Tehmnhirnlfrtlnnt Cunlat (EIC) nw pn>vl& a nnttlailotlornfor euch ttutd b Bhldt fi ptorklet L{rllne *wfctl,
472227 Mud Lake Telephone Coop. Ass'n, lnc.
Sludy Arco Codc(s) (SAC)tiTCNrm(s)
Holdi ng Company Nanre(s)DBA, Markctingor Othcr Branding Nnrn{r)
fliliatcd ETCs (irrclrdr twnrcs and SiCs, attrch
slrccls
Proride a tkr dott fut il:rlr on qliilaretl rtlth tht rcpottltrg ElT, tltllottut tlwll bc lcteniaed h o*tlrrhncr vith sccrlon J(tr) o/thc
Coallltuicatlottt Aci, 'Ilrlt &alon ddtnet "o!filbte" ut "o prsw llwt (llnclly or inllruct$l on'r or contolt, ls oli.nal ot crutrolkcl \,, or
k uxler cuwoaevnerhlpor anntml vhlttuothtpenon." 4T U.SC, i l5r@. Se allio.l7 GF,ll 176.1200,
For purposcs of thls fillng, un oflicer is on occupmt ofa grcsition listcd in thc sniclc of incorporntion, anicles of
fornntiorr, or othcr sirnilar legal docunrcnl. An ofliccr is a pcrson rvho oc'cupirs n positioil sptcitied in thc corporatc
b).lrrrs (or partnenlrlp sgrccmcntlt :rntl rvould typicolly bc prcsidcrrt, vice presidcnt for oJrratiors, vicc prcsidcnt for
firuncc, comprollcr, Hrasurer; or a courporoblc position. lf llrc filer is a sole proprictorship, lhc orvncr inust sign thc
cerriricilIlorr
I ccrtify that the compmy listcd abovc has ccnilication procedurcs in placc eithcr lo:
r\) Rcvierv lnconrc and program.basd eligibility docum€ilatlon prior to errolling o consurlcr irr tlrc Llfclittc
program' ond rhat, to tlrc bcst of nry knorvledgc, thc conrpatly tvds prcscntcd rvith dccumcntalion of eoch
corcumu's house[old lnconrc and/or progrant-bascd cligibllity prior to his or hcr cnrollnrent in Lifeline or
B) Confirm consunrcr cligibilily by rclying upon acccss to n statc datrbasc an<Uor noticc of eligibllity fiont thc
statc Lifclinc dminismtor prior to cnrolling il consurncr in thc Lifclirtc progrsm.
I am on officcr of tlrc cqrnpany naured above. I onr authoriz*d to nrakc thls ccrtilicotion for llu Study Arca(s)
lisrcd above. lnltlal 1(rt
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Approvcd by OMB
3060{819 l
A B c
Nrnbrref
S.Lr..llcri Cldd.d or
frbrrrry fCCFornrQl l9T
otcsrrtit tbnr Sii
trlcrCr ltrr
lirrrbcrrl Umt Cblatd dl
trcbrrry FCC Pon{r) {r7
ofclr,rtul Porlt $t!
crlcndrycrr proildcd to
lllrcllr* Rsclkr*
Nrotrr rl Sulccrlltcrt ddild
rr th FrbnrrT FCCf.r{r)
afl tbrt rl'.rc Irlthlu trillk{ Itcltrtlt Fofln S(i srltrdff r'crt
*0 o
lnltktl tlu ccrtllicatlons belox. tlut apply ta your ETC au4l complev rlu tablts corrgspondlng lo rlw ceriljcatlon below, Depruthry
ut ilE $tote, BOru CEnflnC;nTlON d iND b ,llif ifFlf,
A) I ccnify thlt tlrs comprny listed abovs hns proccdues in placc to r.ccilify thc continued cligibility of all of its
Litbline subscribcrs, and that, io thc bcst of nry knor{edgt, thc company obtained slgrtcd ccrlilications fiont all
suhcribem attciting to tlrcir contlnulng cllgibllity for Lifctinc, Resuls 0ro provlded in thc chart bclorv. I m nn
officer of thecompany namcd above. I am authorizcd to mqke ttris ccrtilicatlon for thc Study Arca(s) llslcd nbovc,
Inlrirl _
D u F.D.8 G llr(F+cl I
NsmDcr ot
$ubrcrlbtn ETC
Cootrctcd Dlrcrtly
to llcccrrlfl,
Ell;lbltty'throush
Att6lrrLn
f{umbcr ol
$ubrcribco
Rupondhr to
ETC Cbnlirt
lluubcr of Noa-
Rofondlal
Subrcrltc:r
l{tmbrr ol
Sub*crlbcnRrrpondlag1trt
Thcy Arc No
Lo4cr Ellglhk
Nuil$cr ofSuhrcrlblru
llc.rnrollcd or
$chrdllcd to bc llc.
]larollcd ls r Rcsult of
No*.!{6ponr orlmlhlbllttr
l{urnhr of
$utrcrlbcrt tVho
DcErru.lhd Prkrr
to llcccrtltl8ltfoa
rtlrcqqlt
t I o a a
AND/OR
ln ilfi space hclov, plca$e llst tln progronr efit lblll$ tldla sQurc€.i, wch ds ETC acse.rl ,a o ttale dtttabase amllot notlca ot
tllglbltltyfmm tlw tav Lfrlitw rlrrlnlttl.um@t at ilt$ Urrirrrra/$cn'fc6 idnlntstrstiw Coutpony (l,lSdQ), nnd lxllcatator vhich
guoltlylng prograus (*6, S.\[t4 SS7, thesd sowr'et ctre wcel to rwl$ ahxrlber eltglbllltl,, [aq, olsriQttlbvx aru
snbtequently canroctcil ilircctly hy the EtC itt t n dltenpt to rcceat$, rll1lbllity, those sabscrlbts ihouhl he lirteil tu cohmnt D
tbough I os opproprlute anl ngt ltt coluansJ through L
6) I ccrtify that thc conrpony listed abovc hns proccdurcs in plrcc to rc-ccrtil'y consunlcr cligibility by rclying on
Acllon of ldaho Rcsults rre
in tha . I anr drr to nlako rhls
FCC Form 55i
D*mber2013
Sgctiou ?; All ETC:s OruST COill PL EfE S ECTI OtlJ 2- Annual Recertlficutlon
Do ni ledvc mpry calnilrils, I an ETC has nothhtg to reporl lil a cohtmn, iltrlr a :ero.
cerrilicnrion for rhe study Are(s) llstcd hbovc.
lhc comDmv nnmcd n
Itrltlsl' {Fl
.I K l.
ilrl$lUCr O, Sllql.tlD{tt
Wtqre f,.lllbility rrs
Rcrt<wal.ByStrtr
,ldrnlnlrlrrtor
FIC Atrcr to El[ibllltyDrir or bv U&IC
I{urlbrr oI
Srhocrlbcrr Oc.f, a rqllfil or
Schtrtrltd to lto lt+Enrollcd rr rRellt oI Flrrtiog of lnclffiblllty by
$trtc rtdnrlalrt reior, E?C Accgr to
Blhlblllty Dru or U$AC
ilomlrcf 0tsrlrcdbc|t lv[o
Dc.Eoroltcrl l'rlor lo
Rccrrlillcrlloo rtrlrngtl
at tl o
OR
C) I certify tlnt nr)r cAmpany did not claim fcdcral lorv incomc suppofi for any Lifelinc subscribcrs for the February
Form 497 duu month for the crrrrerrt fonn 555 calcndsr ycar, I nrn an ofliccr oItltc con{xury rumlcd above. I anl
iluthorizcd to rnake this certiliciliion for the Study Arer(s) listed abore. tultinl
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FCCForm 555
Deccmbcr 2013
Ssction 3: ALL ETCS L'lUSf CO*IPLEfiE SECTION i - De.enroll perco,ilage
)|that k thc percentagc of snbseilhen dc<nrcllctlfor thh ETC?
$sctiou 4: ALL tifCS NIUS'I'CQMPLETE AFPROPRIA'fE CTIECK BOX; ltRE-PrtlD ETCS MUS1.
CONIPLETE ALL OF SESTION 4
ls thc ETC Pre-Pald?
f* fl N, El (l ?re.t'atd tTtC clots t o! (rJscw orcollail o nourhty/tt/ront tt$ L&tlns iuhtcrlbcrs)
Itycs, record the namber ofsub.rcrlbers da-enrolladlot non uioge by month lu colunm I below.
Non.Usage R*nhsAppllcablc to Pr*Pi,ld ETCr:
R s
Ilfonth Suhscrlbors l)o.Enrotlcrt for Noa-Usncc
Januarv
Fcbruarv
March
Aoril
lvlry
Junc
Julv
Aunusl
Scotcmbcr
Octobcr
Novcmber
Dcccnrbcr
$ i $Fhrrq BloS k : I LL ETC$ tV UST Coiff L ET E S lONnT'U RE F I E L DS
By signing bclcrv, I ccrtify tlril lhe conrpeny llstcd abovc is in contplloncc rvith nll fcdcral Lifilline ccrtilication
procedures. I am an ofliccr ofthc conlpany nanted abovc. I am authoriz.ctl to rnakc this certilication for thc Study
rlrea(s) ligtcd aborrc.
Approvett by OMB (3060-08t9 \
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11t N o PrN+O O.lrP+.vtr lool
!tuDD.rof
$rlqcdbtn Clrlatd
er ftbrur; fCCfrrs{rll,,
lllaeColrnltdl
Nrubcr e3$rbrctlttr
Dt f,ors[rdor
*lahlcd to h llo
Sr'.llcdrrr narlof
Nm.Rrqoucor
hclllfitllty
{fuo*Cot\ffit0
N3sDct.tsrhr.rh..j
Ilc. f,rtt&{ rr
Sclcddctl h bc t!*
Errol,.dgrnc$tltof
r Fhdlrgollrdllblllty
(FturColtwK)
Totrl i$nb.ro(
Snbcrtbcn tlo.f,rrcXal
or$tlahlcd lo bc Dof,
lrolled
fcttt.lrl..ts.td(dtcrll*f rrr$al cr $hcdrtr{ tr
lr! DlGrttthd lhl ncrt
Cblrt{oo tlc
fcirurry TCG Fcrur(i) .lf I
50 0 14 14 28o/o
Approvcd by OMB
1060{819FCC Form 555
Dcccrnber 2013
Signed,
Randy Msad
Printcd Name of Oflicer
au30t2014GenerFlManag.g .. _ _Titlc of0fticcr
Ran{y-.1tla?d .,_ " - .- .- . .,
Pcrson Cornpleting this Ccrtilication Form
Datc
(208)374-S01
Contact Phonc Nurnbcr
E'l'C ldcntification
sAc l?l'C Nnnre
4?2?7 htld Lrfr Talools.u Coos*lvs Asrociatho. lnc,
or Other Brandir
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Approvcd by OMB
3060-0819FCC t'ont 555
Dcccmber ?013
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