20170201Mud Lake Form 555.pdf

FCCFormSSS
May2016
472227
Annual Lifeline Eligible Telecommunications Carrier Certification Form
All camers must complete all or portions of all sections
Fonn must be submitted to USAC and filed with the Federal Communications Commission
IMJP>ORTANT:PLEASEREADINS1'RUCTIONSFIRST
Deadllne:January3ld(Annually)
143002519
Study Area Code (SAC) Service Provider Identification Number (SPIN)
0MB Approval
306().()819
(An Eligible Telecommunications Carrier (ETC) must provide a certljlcationformfor each SAC through which U provides Lifeline service).
2016 Idaho
Recertification Year State
DBA, Marketing, or Other Branding Name
(I/ same as EiC name, list "NIA "Do IJ!lLleave blank)
Does the reporting company have affiliated ETCs?
Mud Lake Telephone Cooperative Ass'n, Inc.
ETCName
Holding Company Name
(If same as ETC name, list "NIA" Do not leave blank)
Yes 0
Provide a list of all E'/'Cs 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 "q/Jlllate" as "a person that (directly or indirectly)
owns or controls, 11 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.
I Affiliated ETC's SAC rffiliated ETC's Name
For purposes of this filing, an officer is an occupant of a position listed in the article of incorporation, articles of
fonnation, 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 zypically 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.
SfletJon J; lCnitiaD Certification All EfCs 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 lmowledge, 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) Confinn 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. ~1&11-
FCCPonn5SS
May2016
0MB Approval
3060-0819
semoo 2; Annual Reeertifieation
Do not leave empl)J blocks. If an ETC has nothing to reporl in a block, enter a zero.
A B C D Ei:.s(A-B-C-D)
Number of subscribers Number oflines Number of subscribers dalmed on the Number of subscribers Numberof
claimed on February claimed on February February FCC Form 497 that were de-enrolled ed9J: to subscribers ETC is
FCC Form 497 of FCC Form 497 of !BW!!!1 enrolled In the current Form recertification attempt responsible for
current Form 555 current Form 555 555 calendar year by either the ETC, a recrifylng for calendar year state administrator, calendar year access to an ellglbility current Form SSS
(Februa,., data month) provided to wlrellne (These su/Jsalbm did not h<We J.Vdlne database, or by USAC calendar year
resellers 1mlee prior to Ja1111a,y I of the t:11rrent SSS
caJattla, year.)
Zi 0 0 0 it
Recertification Results:
F
Number of
subscribers ETC
contacted directly to
recertify eligibility
through attestation
0
K
Number of
subscribers whose
ellglblllty was
reviewed by state
administrator,
ETC access to eligibility
database, or by USAC
0
Certification:
G Hc(F-G) I Ji:.s(H+I)
Number or 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-eorolled as
a result of finding of
Jneliglbllity by state
administrator, ETC access to
eliglblllty 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
(Ttds should be a su/Jset of Blodi ineligibillty from ETC
G.) recertification attempt
0 c::s
Note: If any subscriber was reviewed by an ErC accessing a stale database or
by a slate administrator and subsequently contacted direclly by the EfC In an
allempt to recertlb eligibility, those subscribers should be listed In Blocks F
through J as appropriate and not in Blocks Kand L .4s a result, all 81lbscrlbers
subject to recertification who were not de-enrolled prior to the recertljlclJtion
attempt must be accounted/or In Block For Block K.
The total of Block F and Block K should equal the number repqrted In Block
E.
Based on the data entered above. initial the certiftcation(s) below that apply. Boll, Certification A and B may apply depending on the recertljlcation
procedures In place for the SAC reporting on this form. If Certification C applies, neither Certil/catlon 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 lmowledge, 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
throu,JJ ;rm an officer of the company named above. I am authorimd to make this certification for the SAC listed
above. ./
Initial '
AND/OR
B) I certify that the company listed above has procedures in p1acie ~~ify consumeniligibility by relying on:
S:\:s"1e: Msnoirais+ca:1:oc .. ~p,e,d:Yn~.+ ~~H:h 4'sae2 JAkJ~re
(List database or name of adminlatralor here)
Results are provided in the chart above in Blocks K through L. I am an officer of the company named above. I am
authori7.ed to make this certification for the
Initial .
OR
SACl~ove.
C) I certi that my company did not claim federal low income support for any Lifeline subscribers for the February
Form 497 data month for the cumnt Fonn SSS calendar year. I am an officer of the company named above. I am
authori7.ed to make this certification for the SAC listed above. Initial __ _
2
FCC Fonn SSS 0MB Approval
May 2016 3060-0819
Sec;tinp 3; J>e.enroll Percentage
Using the dala entered in Section 2. complete the chart below tojlnd the percentage ofmbscrlbers de-enrolled/or this ETC.
M=(F+K) Ns::(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 dwnrolled or scheduled to
2t.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 lneUgibillty or non-response
byUSAC inellglbillty
(77,/s should equal the mun/Jer repo,ted
in Block BJ
D 6 6
$e#ionf; ETCs Subject to the Non-Usage Requirements
All EfCs 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. El'Cs subject to the non-usage requirements must lndlcale the number of subscribers de-enrolled by month in Section
4. £TCs that only anen afee but do not collect such fees are subject to the non-mage requirements and must also indicate the number of
subscribers de-enrolled by month.
Is the ETC subject to the non-usage requireinents?YesO No~
If yes, record the number of subscribers de-enrolledfor non-usage by month in Block Q below.
p 0
Month Subscribers De-Enrolled for Non-Usaae
January
February
March
Aoril
May
June
July
Auaust
September
October
November
December
Total Subscribers
Signature Bloek
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 authori?.ed to make this certification for the
Study Area Code (SAC) listed above.
Simted, ~ {di:+ jj, J.ryBpy;. :r CA..~il\ ~tSet'/e~~
Printed Name and Title of Officer
t/1t?IZ9&1
Person Completing This Certification Fonn Contact Phone Number
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