20170118Custer Broadband Form 555.pdf

FCC Form 555
November 2016
479019
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)
143031048
0MB Approval
3060-0819
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier (ETC) must provide a certification form for each SAC through which it provides Lifeline service).
2016 ID
Recertification Year State
N/A
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "NIA" Do not leave blank)
Does the reporting company have affiliated ETCs?
Custer Telephone Broadband Services LLC
ETC Name
Custer Telephone Cooperative, Inc.
Holding Company Name
(If same as ETC name, list "NIA" Do not leave blank)
Yes [i] No [ill
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 US. C. § 153 (2). See also 47
C.F.R. § 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
--See attached worksheet --
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 J; 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 ~
FCC Form 555 Approved by 0MB
November 2014 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 recertifying for calendar year calendar year state administrator, current Form 555
provided to wireline (These subscribers did not have Lifeline access to an eligibility calendar year (February data month) resellers service prior to January 1 of the current 555 database, or by USAC
calendar year.)
12 0 0 0 12
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 directly 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
0 0 0 0 0
K
Number of
subscribers whose
eligibility was
reviewed by state
administrator,
L
Number of
subscribers de-enrolled or
scheduled to be de-enrolled as
a result of finding of
ineligibility by state
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.
ETC access to eligibility
database, or by USAC
administrator, ETC access to
eligibility database, or USAC The total of Block F and Block K should equal the number reported in Block
E.
12 0
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:
Idaho Denartment of Health & Welfare . (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 company named above. I am
authoriz~ufm,{e 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 ----
2
FCC Form 555 Approved by 0MB
November 2014 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 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
byUSAC non-response or
(This should equal the number ineligibility
reported in Block E)
12 0 0.0%
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 numoer 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 requirements? Yes [Q] No [al
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 0
February 0
March 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. "
-?res ,cicV\t
~cz(~ 's~re of Officer
Denn·,s L Thornoc.L
Printed N~~d Title of Officer --7-J_Lt,7 2 07T [e-mail]
Email Address of Officer Date
Teresa Westergard 208-879-2281
Person Completing This Certification Form Contact Phone Number
3
FCC Form 555
November 2014
SAC
472218
.
Affiliated ETCs
Name
Custer Telenhone Coonerative Inc .
Approved by 0MB
3060-0819
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