20170117Rural Telephone (RTI) Form 555.pdf

FCC Form 555
May2016
472233
Annnal Lifeline Eligible Telecommnnications Carlier Certification Form
All carriers must complete all or portions of all sections
Fonn must be submitted to USAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 3]81 (Annually)
143002523
Stndy Area Code (SAC) Service Provider Identification Number (SPIN)
0MB Approval
3060-0819
(An Eligible Telecommunications Can·ier (ETC) must provide a certification form for each SAC through which it provides Lifeline service).
2016 IDAHO
Recertification Year State
RTI RURAL TELEPHONE COMPANY
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "NI A" Do not leave blank)
Does the reporting company have affiliated ETCs?
RTIRURAL TELEPHONE
ETC Name
RURAL TELEPHONE COMPANY
Holding Company Name
(If same as ETC name, list "NIA" Do not leave blank)
Yes []I NoD
Provide a list of all ETCs that are affiliat"ed with the ref)orting ETC, usini page 4 afld addiiional sheetS if necessa,y. 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
552233 RTI RURAL TELEPHONE
For purposes of this filing, an officer is an occupant of a position listed in the article of incotporation, 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 wonld 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 ai1d/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 ce1tification for the Study Area Code listed
above.
I
FCC Form 555 0MB Approval
May2016 3060-0819
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 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 497 of FCC Form 497 of initially enrolled in the current Form recertification attempt responsible for
current Form 555 current Form 555 555 calendar year by either the ETC, a ~ecertifying for calendar year state administrator, calendar year access to an eligibility current Form 555
(February data mo11tlt) provided to wireline (These subscribers did not h«ve LifeHue database, or by USAC calendar year
resellers service prior to January I oftlte curre11t 555
cale11dar year.)
7 0 0 0 7
Recertification Results:
F
Number of
subscribers ETC
contacted directly to
recertify eligibility
through attestation
0
K
Number of
subscribers whose
eligibility was
reviewed by state
administrator,
ETC access to eligibility
database, or by USAC
7
Certification:
G H=(F-G) I J= (H+I)
Number of Number of non-Number of subscribers Number of subscribers de-
subscribers responding responding to ETC subscribers contact
0 0
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
0
responding that they are enrolled or scheduled to be
no longer eligible de-enrolled as a result of
non-response or response of
(Tltis should be a subset of Block ineligibility from ETC
G.) recertification attempt
0 0
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 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.
The total of Block F amt Block K should equal the number reported in Block
E.
Based on the data entered above, initial the certijication(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 rece1iify 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 chrui above in Blocks F
through J. I am an officer of the company named above. I am authorized to make this ce1iification for the SAC listed
above.
B)
Initial --· AND/OR
I certifythat the company listed above has procednres in place to rece1iify consumer eligibility by relying on: Salix
{List database or name of administrator here)
Results are provided in the chart above in Blocks K through L. I am an officer of the compruiy named above. I am
authorized to make this certification for the
SAC listed. 901,"f'·
Initial .//, /? /,
/ 00
C) I certif/lhat my company did not claim federal low income support for any Lifeline subscribers for the Februal)'
Form 497 data month for the current Form 555 calendru· year. I am an officer of the company named above. I am
authorized to make this certification for the SAC listed above.
Initial ----
2
FCCForm555
May2016
0MB Approval
3060-0819
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) 0 = ((N + M) * 100)
Number of subscribers that the Number of subscribers Percentage of subscribers
ETC attempted to recertify directly de-enrolled or scheduled de-enrolled or scheduled to
m:..through a state administrator, to be de-enrolled as a be de-enrolled as a result of
ETC access to a state database, or result of non-response or ineligibility or non-response
byUSAC ineligibility
(This shoulil equal the number teporled
ill Block E)
7 0 0.00
Section 4; ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropriate check-box. ETCs that do not assess and collect a monthly fee from their Lifeline subscribers are subject to
the non-usage requirements. ETCs subject to the non-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 month.
Is the ETC subject to the non-usage requiremeuts?YesD No~
Jfyes, 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.
Signature of16ffic
mike.mafle @ruraltel.org
Email Address of Officer
Theresa Wilson
Person Completing This Certification Form
Mike Martell, Vice President
Printed Name and Title of Officer
01/16/2017
Date
208-366-2614
Contact Phone Number
3
FCC Form 555
May2016
SAC
Affiliated ETCs
Name
0MB Approval
3060-0819
4