20170111Direct Communications Rockland Form 555.pdf

FCC Form 555
November 2016
472232
Annual Lifeline Eligible Telecommunications Carrier Certification Form
All carriers must complete all or portions of all sections
Forni must be submitted to USAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31st (Annually)
143002522
0MB Approval
3060-0819
Sh1dy Arca Code (SAC) Service Provider Identification Number (SPIN)
(A11 Eligih/e Telec:omm1111icatio11s Carrier (ETC) must provide a cert/[tcation(ormfor each SAC through which it provides Lifeline service).
2016 ID
Recertification Year State
N/A
OBA, Marketing, or Other Branding Name
(l(sa111e as ETC 11a111e. list "NIA" Do ,wt leave b/a11k)
Does the reporting company have affiliated ETCs?
Direct Communications -Rockland Inc.
ETC Name
N/A
Holding Company Name
(If same as ETC name, list "NIA" Do 1101 leave blank)
Yes [o] No ufil
Pro,·ide a list o.( all ETCs that are affiliated with the reporting ETC, using page 4 and additional s/1eets /(necessary. A.[[tliation shall be
dt'lern1i11ed in accordance ll'ilh Section 3(2) o.fthe Communications Act. That Section defines "affiliate" as "a person that {directly or indirectly)
011·11s vr controls, is o wned or controlled by, or is under co111111011 ownership or contml with, another person." 47 U.S.C. § 153(2). See also 47
CF.Rf 76 /2()()
Affiliated ETC's SAC Affiliated ETC's Name
'-------------------------~-------------------------'
For purposes of this filing, an officer is an occupant of a pos1t1on listed in the article of incorporation, aiticles 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 incotnl' ;t11d program-based eligibility documentation prior to emolling 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 Sh1dy Area Code listed
above.
I .. I JS mha ----
FCC Form 555 Approved by 0MB
November 20 14 3060-0819
S1,~ction 2: Annual Recertification
lJo 110 / lca 1·e empty hlocks. If an ETC has 11othi11g to report in a block, enter a zero.
A B C D E = (A -B -C -D)
Number of subscribers Number of lines Number of subscribers claimed on the Number of subscribers Number of
claimed on February claimed on February February FCC Form 497 that were de-enrolled prior to subscribers ETC is
FCC Form .t97 of FCC Form 497 of initially enrolled in the current Form recertification attempt responsible for CUITCnt Form sss current Form 5SS 555 calendar year by either the ETC, a recertifying for calendar year calendar year state administrator, current Form SSS
provided to wirelinc (These subscribers did 11ot have Lifeli11e access to an eligibility calendar year (Febrt1111J' data 111011th) resellers service prior to Ja1111ary I of the current 555 database, or by USAC
cale11dar year.)
14 0 1 3 10
Recertification Results:
F G H = (F-G) I J = (H+I)
Number of Number of Number of non-Number of subscribers Number of subscribers de-
subscribers ETC subscribers responding responding that they are enrolled or scheduled to be contacted directl) to responding to ETC subscribers no longer eligible de-enrolled as a result of
recertify eligibility contact non-response or response of through attestation (This should be a subset of Block ineligibility from ETC
G.) recertification attempt -
2 2 0 0 0
---·--
K
Number of
subscribers whose
eligibility was
reviewed by state
administrator,
ETC access to eligibility
database, or by USAC
8
Certification:
L
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
2
Note: ff any subscriber was reviewed hy an ETC accessing a state database or
by a state administrator a11d s11bsequently contacted directly by the ETC i11 an
at/empt to recert/[v eligibility, those subscribers should be listed in Blocks F
through J as appropriate and not in Blocks Kand 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 For Block K.
Tire total of Block F and Block K slro11/d equal tire 1111111ber reported i11 Block
E.
/Jased 011 the data entered above, initial the certification(s) below that apply. Both Certification A and B may apply depending on the recertificalion
pmcedures in place/hr the SAC reporting on this.form. ff 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 ce1iifications from all
subscribers attesting to their continuing eligibility for Lifeline. Results are provided in the chart above in Blocks F
through J. i am a n officer of the company named above. I am authorized to make this certification for the SAC listed
above.
Initial _J....;S __ _
AND/OR
B) I certify that the company listed above has procedures in place to recertify consumer eligibility by relying on:
Camnrnnitv A ctian Partnershin A ssaciatian of Idaho . (list database or name of administrator here) Results
arc 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 _J_S __ _
OR
C) J cetiify that my company did not claim federal low income support for any Lifeline subscribers for the Febmary
Form 497 data month for the current Fom1 555 calendar year. 1 am an officer of the company named above. T am
authorized to make this certification for the SAC listed above.
Initial ___ _
2
FCC Form 555 Approved by 0MB
November 2014 3060-0819
Section 3: De-enroll Percentage
Usi11g tl,e data rntered in Section 2, complete the char/ below to find the percentage of subscribers de-enrolledfor this ETC.
----
M = (F+K) N = (J+L) 0 = ((N + M) * 100)
Number of subscribers that the Number of subscribers Percentage of subscribers
ETC attempted to recertify directly de-enrolled or de-enrolled or scheduled to
or through a state administrator, scheduled to be de-be de-enrolled as a result of
ETC access to a state database, or enrolled as a result of ineligibility or non-response
by USAC non-response or
(This should equal the 1111111her ineligibility
reported in Bloc!< £)
10 2 20.0%
Section 4: ETCs Subject to the Non-Usage Requirements
All ETCs 11111st complete the appr(ij)riate check-box. ETCs that do not assess and collect a 111onthlvfeefrom their Lifeline subscribers are subject to
tire non-usage requirements. ETCs subject to the 11011-usage requirements must indicate the number of subscribers de-enrolled by month in Section
4. ETCs that only assess a fee but do not collect such fees are subject to the non-usage requirements and must also indicate the number of
subscribers de-enrolled by 111011th.
Is the ETC subject to the non-usage requirements? Yes~ No~
!(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 0 -·
1-"ehruarv 0 ~. -
Marc h 0
April 0
May 0
June 0 -
July 0
August 0
September 0
October 0
November 0 -
December 0
Total Subscribers 0
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,
Certitied Online
Signalure oi"Officer
[e-mail]
Email Address of Officer
Tina Ellett
Person Completing This Ccrtilication Form
General Manager
:s(/'""'11~ r,,r(, c ~
Printed Name and Title of Officer
01/10/2017
Date
208-548-2345
Contact Phone Number
3