HomeMy WebLinkAbout20170120Blackfoot Telephone Cooperative, Inc. Form 555.pdfJanuary 20, 2017
Idaho Public Utilities Commission
472 W. Washington
Boise, ID 83720
Lifeline Re~~hi~florf !a!~Cc5fof~5!Pula. MT 59808
866-541-5000 I Blackfoot.com
Re: WC Docket No. 14-171 and IPUC Case NumberGNR-T-17-01
Blackfoot Telephone Cooperative, Inc. respectfully submits the attached certifications pursuant to 47
CFR §54.416 (b) and 54.410 (d) as required by the FCC's Lifeline Reform Order. The filing has been
mailed in accordance with the Commission's Public Notice DA 14-1731.
Sincerely,
Michelle Owens
Regulatory Specialist
Blackfoot Telephone Cooperative, Inc.
1221 N. Russell St.
Missoula, MT 59808
cc: FCC Secretary
Montana Public Service Commission
USAC High Cost & Low Income Division
Confederated Salish & Kootenai Tribes
r:cc Form 555
November 2016
482235
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: Janua,y JP' (Annually)
143002531
0MB Approval
3060-0819
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Teleco111111unicalions Carrier (ETC) 11111s1 provide a cerlijicationformfor eacft SAC through which it provides Lifeline service).
2016
Recertification Year
Blackfoot
MT
State
OBA, Marketing, or Other Branding Name
(ff same as ETC name, list "NIA" Do not leave blank)
Does the reporting company have affiliated ETCs?
Blackfoot Telephone Cooperative Inc.
ETC Name
BTC HOLDINGS INC
Holding Company Name
(ff same as ETC name, !isl "NIA" Do no1 leave blank)
Yes ffi] No fi5)
Provide a list of all ETCs that are affiliated with the reporling ETC, using page 4 and additional sheets if necessary. Affiliation shall be
determined in accordance wilh 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 Affi liated ETC's Name
--See attached worksheet --
For purposes of this filing, an officer is an occupant of a position listed in the a1ticle of incorporation, a1t icles 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 fi ler is a sole proprietorship, the owner must sign the certification.
Section 1; Initial Certification All ETCs must complete !his section
I certify that the company listed above has ce1tification 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.
I .. 1 mag mha
FCC Form 555 Approved by 0M B
November 20 14 3060-0819
Sectjon 2: Annual Recertification
Do no/ leave emply blocks. If an ETC has nolhing lo repor/ in a block, en/er a zero.
A B C D E = (A -B -C -D)
Number of subscribers Number of lines Number of subscri bers 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 1101 h11ve Lifeline access to an elig ibility calendar year
(February data 111011th) resellers service prior to Ja111w,y I of the curre11t 555 database, or by USAC
calendar year.)
200 0 0 40 160
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 rcspondi ng that they arc enrolled or scheduled to be
contacted directly to responding to ETC subscribe1·s
recertify eligibility contact
through attestation
0 0 0
K L
Number of Number of
subscribers whose subscribers de-enrolled or
eligibility was scheduled to be de-enrolled as
reviewed by state a result of finding of
administrator, ineligibility by state
ETC access to eligibility administrator, ETC access to
database, or by USAC eligibility database, or USAC
160 56
Certification:
no longer eligible de-enrolled as a result of
non-response or response of
(This should he a subset of Block ineligibility from ETC
G.) recertification attempt
0 0
Note: If any subscriber was reviewed by an ETC accessing a stale database or
by a state administrator and subsequently contacted direclly by /he JDC in an
a/tempi to recer/ijj1 eligibility, those subscribers should be /isled in Blocks F
through J as appropriate and not in Blocks Kand L. As a resull, all subscribers
subject lo recertification who were no/ de-enrolled prior Jo the recerlifica/ion
a//empl must be accounted for in Block For Block K.
The total of Block F and Block K should equal the number reported in Block
E.
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/or the SAC reporting on this form. 1/Certifica/ion 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 s igned 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 li sted above has procedures in place to recertify consumer eligibility by relying on:
__w.L.J..£::u....~-------------------------· (Lisi 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
authorized to make this certification for the SAC listed above.
Initial ..:..m:...:.a=g __
OR
C) I certify that my company did not cla im 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
Sectjon 3: De-enroll Percentage
Using the data entered in Sec lion 2, complete !he chart below to find !he percenlage of subscribers de-enrolled/or !his ETC.
M = (F+K) N = (J+L) O=((N +M)* 100)
'umber 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 11umber ineligibility
reporled i11 Block E)
160 56 35.0%
Section 4: ETCs Subject to the Non-Usage Requirements
A II ETCs mus/ complete 1he apprqpriate check-box. ETCs that do not assess and collect a monthly.fee from their lifeline subscribers are subj eel lo
!he non-usage requirements. ETCs subject lo the non-usage requirements must indicate the number of subscribers de-enrolled by month in Section
4. ETCs Iha/ only assess a fee blll do not col/eel such fees are subject to the non-usage requiremenls and must also indica/e !he number of
subscribers de-enrolled by monlh. .
Is the ETC subject to the non-usage requirements? Yes [nJ No IE)
If yes, record !he number of subscribers de-enrolled/or 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.
Signed,
Certified Online
Signature of Officer
mgi llen@blackfoot.com
Email Address of Officer
Michelle Owens
Person Completing This Certification form
Marlys Gillen, Controller
Printed Name and Title of Officer
01/10/2017
Date
401-541 -5131
Contact Phone Number
3
FCC Form 555
November 2014
SAC
483308
472222
Affiliated ETCs
Name
Blackfoot Teleohone Cr,r,npp:itive Inr
Fremont Telcom Co.
Approved by 0 MB
3060-08 19
4