20150130Columbine Telephone-Silver Star 555.pdf

FCC Form 555
November 2014
Approved by OMB
3060-0819
1

Annual Lifeline Eligible Telecommunications Carrier Certification Form All carriers must complete all or portions of all sections Form must be submitted to USAC and filed with the Federal Communications Commission IMPORTANT: PLEASE READ INSTRUCTIONS FIRST Deadline: January 31st (Annually)
Study Area Code (SAC)
(An Eligible Telecommunications Carrier (ETC) must provide a certification form for each SAC through which it provides Lifeline service). State ETC Name DBA, Marketing or Other Branding Name Holding Company Name (If same as ETC name, list “N/A” Do not leave blank) (If same as ETC name, list “N/A” Do not leave blank)
Does the reporting company have affiliated ETCs? Yes No
Provide a list of all ETCs that are affiliated with the reporting ETC, using page 4 and additional sheets if necessary. Affiliation shall be determined in accordance with Section 3(2) of the Communications Act. That Section defines “affiliate” as “a person 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. § 153(2). See also 47 C.F.R. § 76.1200.
Affiliated ETC’s SAC Affiliated ETC’s Name

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 1: Initial Certification All ETCs must complete this section

I certify that the company listed above has certification procedures in place to: A) Review income and program-based eligibility documentation prior to enrolling a consumer in the Lifeline 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; and/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 Study Area Code listed above.
Initial
472295
JHE
Columbine Telephone Co. Inc
Silver Star Communications Horizon Communications, Inc.
-- See attached worksheet --
ID
FCC Form 555
November 2014
Approved by OMB
3060-0819
2

K L
Number of subscribers whose eligibility w as review ed by state
administrator, ETC access to eligibility database, or by USAC
Number of subscribers de-enrolled or scheduled to be de-enrolled as a result of finding of ineligibility by state administrator, ETC access to eligibility database, or USAC

Section 2: Annual Recertification
Do not leave empty blocks. If an ETC has nothing to report in a block, enter a zero.
A B C D E = (A – B – C – D)
Number of subscribers claimed on February FCC Form 497 of current Form 555 calendar year (February data month)
Number of lines
claimed on February
FCC Form 497 of
current Form 555
calendar year
provided to wireline
resellers
Number of subscribers claimed on the
February FCC Form 497 that were
initially enrolled in the current Form
555 calendar year
(These subscribers did not have Lifeline
service prior to January 1 of the current 555
calendar year.)
Number of subscribers de-enrolled prior to recertification attempt by either the ETC, a state administrator, access to an eligibility database, or by USAC
Number of
subscribers ETC is
responsible for
recertifying for
current Form 555
calendar year

Recertification Results:
F G H = (F-G) I J = (H+I)
Number of subscribers ETC contacted directly to recertify eligibility through attestation
Number of subscribers responding to ETC contact
Number of non- responding subscribers
Number of subscribers responding that they are no longer eligible (This should be a subset of Block G.)
Number of subscribers de- enrolled or scheduled to be de-enrolled as a result of non-response or response of ineligibility from ETC recertification attempt

Note: If any subscriber was reviewed by an ETC accessing a state database or by a state administrator and subsequently contacted directly by the ETC in an attempt to recertify eligibility, those subscribers should be listed in Blocks F through J as appropriate and not in Blocks K and L. As a result, all subscribers subject to recertification who were not de-enrolled prior to the recertification
attempt must be accounted for in Block F or Block K. The total of Block F and Block K should equal the number reported in Block
E. Certification: Based on the data entered above, initial the certification(s) below that apply. Both Certification A and B may apply depending on the recertification
procedures in place for the SAC reporting on this form. If Certification C applies, neither Certification A nor B may apply.
A.) I certify that the company listed above has procedures in place to recertify 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 above in Blocks F through J. I am an officer of the company named above. I am authorized to make this certification for the SAC listed
above.
Initial AND/OR B.) I certify that the company listed above has procedures in place to recertify consumer eligibility by relying on:
. Results are provided in the chart above in
Blocks K through L. I am an officer of the company named above. I am authorized to make this certification for the SAC listed above.
Initial
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 current Form 555 calendar year. I am an officer of the company named above. I am authorized to make this certification for the SAC listed above. Initial
JHE
Community Action Partnership Association of Idaho
0 0
45
0
45 5
0 0
0 5500
FCC Form 555
November 2014
Approved by OMB
3060-0819
3

Section 3: De-enroll Percentage
Using the data entered in Section 2, complete the chart below to find the percentage of subscribers de-enrolled for this ETC.
M = (F+K) N = (J+L) O = ((N ÷ M) * 100)
Number of subscribers that the
ETC attempted to recertify directly
or through a state administrator,
ETC access to a state database, or
by USAC
(This should equal the number
reported in Block E)
Number of
subscribers de-
enrolled or scheduled
to be de- enrolled as a
result of non-response
or ineligibility
Percentage of subscribers
de-enrolled or scheduled to
be de-enrolled as a result of
ineligibility or non-response

Section 4: Pre-Paid ETCs
All ETCs must complete the appropriate check-box; pre-paid ETCs must complete all of Section 4. Pre-paid ETCs generally do not assess or collect a
monthly fee from their Lifeline subscribers. ETCs that only assess a fee but do not collect such fees are pre-paid ETCs and must complete the chart below. Is the ETC Pre-Paid? Yes No
If Yes, record the number of subscribers de-enrolled for non-usage by month in Block Q below.
P Q
Month Subscribers De-Enrolled for Non-Usage
January
February
March
April
May
June
July
August
September
October
November
December
Total Subscribers
Signature Block 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 Code (SAC) listed above.
Signed,
Signature of Officer Printed Name and Title of Officer
Email Address of Officer Date
Person Completing This Certification Form Contact Phone Number
307-883-6690
0
0
Jefferson H. England, CFO
0
Michelle Motzkus
0
0
0
11.12%5
0
0
45
0
0
Certified Online
[e-mail] 01/07/2015
0
0
0
FCC Form 555
November 2014
Approved by OMB
3060-0819
4

Affiliated ETCs
SAC Name

Gold Star Communications LLCGold Star Communications LLC
Silver Star Telephone Co. Inc.
Silver Star Telephone Co. Inc.
512295
519001
519005479011