20170202Inland Telephone Form 555.pdf

INLAND TELEPHONE COMPANY
Corporate Offices
103 S. 2nd St.
P.O. Box 171
Roslyn. WA 98941
Telephone: [phone]
Fax: [phone]
February 1, 2017
INLAND
TELEPHONE
Via email in .PDF format to [e-mail]
Idaho Public Utilities Commission
Commission Secretary
4 72 W. Washington
P.O. Box 83720
Boise, ID 83720-007 4
Re: Pursuant to IPUC Order No. GNR-T-16-01
201 7 Federal Lifeline Certification and Reporting
Pursuant to 47 C.F.R. § 54.416(b)
Dear Commission Secretary:
Pursuant to 47 C.F.R. § 54.416(b), accompanying this letter for
filing with the Idaho Public Utilities Commission ("Commission") is a copy
of the completed Federal Communications Commission ("FCC") Form 555
(Annual Lifeline Eligible Telecommunications Carrier Certification Form),
for the reporting year ended December 31, 2016. The FCC Form 555 has
been submitted pursuant to the FCC's Lifeline program rules and WC
Docket No. 14-171 by Inland Telephone Company ("Company")(SAC
472423) to the Universal Service Administrative Company and the FCC
with respect to the Company's Lifeline service subscribers residing in the
State: of Idaho.
Please let us know if the Commission has any questions regarding
the information presented on the accompanying form.
Sincerely,
Treasurer/ Controller
Accompanying document
FCC Fonn 555
May 2016
472423
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
IMPORT ANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31st (A111111ally)
143002527
Study Area Code (SAC) Service Provider Identification Number (SPIN)
0MB Approval
3060-0819
(An Eligible Teleco1111111111ications Carrier (ETC) must provide a certification form/or each SAC through which it provides Lifeli11e service).
2016
Recertification Year
Inland Networks
ID
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?
Inland Telephone Company
ETC Name
Western Elite Incorporated Services
Holding Company Name
(ff same as ETC name, list "NIA" Do not leave blank)
Yes [Z]
Provide a list of all ETCs that are affiliated with the reporting ETC, using page 4 and additional sheets if 11ecessary. Affiliation shall be
determined in accordance with Sectio11 3(2) of the Co111m1111icatio11s Act. That Section defines "affiliate" as "a person that (directly or indirectly)
owns 01· controls, is owned or coll/rolled 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
522423 Inland Telephone Company
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 --'/2--
FCC Form 555
May 2016
0MB Approval
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 initiallv 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 state administrator,
calendar year access to an eligibility current Form 555
(Febniary tlatn month) provided to wircline (These s11bscribers did not ltnve lifeliue database, or by USAC calendar year
resellers service prior to Jn1111nry I of the c11rretlt 555
cnle11dnr yenr.)
1 0 0 0 1
Recertification Results:
F
Number of
subscribers ETC
contacted directly to
recertify eligibility
through attestation
1
K
Number of
subscribers whose
eligibility was
reviewed by state
administrator,
ETC access to eligibility
database, or by USAC
0
Certification:
G H = (F-G) I J = (1-1+1)
Number of Number of non-Number of subscribers Number of subscribers de-
subscribers responding responding to ETC subscribers contact
1 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 arc enrolled or scheduled to be
no longer eligible de-enrolled as a result of
non-response or response of
( Tltis should be n 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 1101 in Blocks K and l. As a result, all subscribers
subject to recertification who were not de-enrolled prior to the recertification
a/tempi must be accounted for in Block For Block K.
The total of Block F and Block K should equal the number reported i11 Block
E.
Based on the data entered above, initial the certification(:.) below that apply. Both Certification A and B may apply depending on the recertification
procedures in place f,or the SAC reporting on this form. !f Certificatio11 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*-. I a 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:
C)
USAC NLAD
(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
authorized to make this certification for the
OR
SAC listef JOve.
Initial
I certify hat 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 0MB Approval
May 2016 3060-0819
Sectjon 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)
Nu mbcr of subscribers that the Number of subscribers Percentage of subscribers
ETC attempted to recertify directly de-enrolled or scheduled de-enrolled or scheduled to
.QLthrough 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
by USAC ineligibility
(This sho11ld eq11al the 1111111ber reported
ill Block E)
1 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 number of subscribers de-enrolled by month in Section
4. ETCs that only assess a Jee but do not collect such fees are subject to the non-usage requirements and must also indicate the 1111mber of
s11bscribers de-enrolled by month.
Is the ETC subject to the non-usage requirements?YesONo!/l
If yes, record the number of rnbscribers de-enrolled for 11011-11sage 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.
Email Address ofOflicer
James K. Brooks
Person Completing This Certification Form
James K. Brooks, Treasurer
Printed Name and Title of Officer
February 1, 2017
Date
[phone]
Contact Phone Number
3
FCC Fonn 555
May 2016
SAC
Affiliated ETCs
Name
.
0MB Approval
3060-0819
4
_J