20170221Filer Mutual Form 555.pdf

:l;'ltlVED
llll flD 2 t ,1!t 9: 28
S3,lri;'lri.r!+: F,LEFTII,zIUTUAL\iii,..I TelephoneGompany
February 16,2017
Ms. Jean Jewell
Commission Secretary
ldaho Public Utilities Commission
472 W est Washington Street
Boise, ldaho 83720
&NR- T'11-o )
RE: Annual Eligibility RE-Certification of Lifeline Subscribers
Dear Ms. Jewell,
Filer Mutual Telephone Company, lnc. ("the Company" or "File/') hereby provides a copy
of its Annual Lifeline Eligible Telecommunications Carrier Certification FCC Form 555 in
compliance with 47 CFR 54.416 as adopted by the Federal Communication Commission
(FCC) in its Lifeline Reform order, FCC 12-11, released February 6,2012. This filing
contains a copy of the FCC Form 555 submitted to USAC and the FCC on February 1Sth,
2017.
Please call me at [phone] if you have any questions
Sincerely,auu
Robert Kraut
Controller/CFO
Enclosures
472220 14300251 3
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier (ETC) must provide a certificationformfor each SAC through which it prot,ides Lifeline sen,ice\.
2016 lD Filer MutualTelephone Company
Recertification Year
N/A
State ETC Name
N/A
DBA. Marketins. or Other Brandins Name(lf samb as ETC nom"e, list "N A" Do not leafi blankt
Holdins Comoanv Name
(l[sarne oY ETC ,i^r.'list "N A" Do no! leave blankt
FCC Form 555
November 2016
OMI) Approval
3060-08 I 9
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 RBAD INSTRUCTIONS FIRST
Deadline: Jonuary 31't (Annually)
Does the reporting company have affiliated ETCs? Yes [@ No [G[
Provide a list of all ETCs that are affiliated with the reporting ETC, using page I and additional sheets d necessary. Af/iliation shall be
determined in accordance with Section 3(2) of the Communications Act. That Section defines "afiiliate" as "a person that (directU or indirectly)
owns or controls, is owned or controlled by, or is under common ownership or control with, anolher person." 47 I/.S.C. i 153(2). See also 47
c.r.R. $ 76.t200.
Affiliated ETC's SAC Affiliated ETC's Name
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 tlre certification.
Section l: Initial Certification All ETCs must complete this section
I certifo 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 authorizpd to make this certification for the Study Area Code listed
above.
Initial SC
FCC Form 555
November 2014
Section 2: Annual Recertification
Do not leave empty blocks. If an ETC has nothing to report in a block, enter o :ero.
Recertification Results:
K L
Number of
subscribers whose
eligibility was
reviewed by state
administrator,
ETC access to eligibility
database, or by USAC
Number of
subscribers de-enrolled or
scheduled to be de-enrolled as
a result oflinding of
ineligibility by state
administrator, ETC access to
eligibility database, or USAC
33 5
Approved by OMB
30604819
Note: lf any subscriber was reviewed by an ETC accessing a stale dalabase or
by a state administrator and subsequently contacted directllt by the ETC in an
attempt to recertifi; eligibilit-v. those subscribers should be listed in Blocks F'
through J as appropriate and not in Blocks K and L. As a result, all subscribers
subject to recertification who were nol de-enrolled prior to the recertification
atlempt must be accountedfor in Block F or Block K.
The total of Block F and Block K should equal the number rcporled in Block
E.
Certification:
Based on the data entered above, initial the certification(s) below that apply. Both Certification A and B may appllt depending on the recertilication
procedures in place for the SAC reporting on this form. If Certi/ication C applies, neither Certification A nor B may apply.
A) I certifu 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 authorizedto make this certification for the SAC listed
above.
Initiat sc
AND/'RB) I certifu that the company listed above has procedures in place to recertifu consumer eligibility by relying on:
/-^**"-ir', A^+;^- D-*+---ohin Aoo^^;af;^n ^f L{.L^(List database or nanle 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.
Initiat SC
ORC) I certifu that my company did not claim federal low income support for any Lifeline subscribers for the February
Form497 data month forthe current Form 555 calendaryear. I am an officer of the company named above. I am
authorized to make this certification for the SAC listed above.
Initial
2
A B C D E=(A-B-C-D)
Number ofsubscribers
claimed on February
FCC Form 497 of
current Form 555
calendar year
(February data monthl
Number of lines
claimed on February
FCC Form 497 of
current Form 555
calendar year
provided to wireline
resellers
Number of subscribers claimed on the
February FCC Form 497 thatwere
initially enrolled in the current Form
555 calendar year
(These subscriben did not have Lileline
semice prior to Jonuary I of the currenl 555
calendar year.)
Number of subscribers
de-enrolled prior to
recertifi cation attempt
by either the ETC. a
state administrator,
access to an eligibility
database, or by USAC
Number of
subscribers ETC is
responsible for
recertifying for
current Form 555
calendar year
33 0 0 0 33
F G s = 1F_c)I J = (H+t)
Number of
subscribers ETC
contacted directly to
recertify eligibility
through attestation
Number of
subscribers
responding to ETC
contact
Number of non-
responding
subscribers
Number ofsubscribers
responding that they are
no longer eligible
(This should be o subsa of Block
G.)
Number of subscribers de-
enrolled or scheduled to be
de-enrolled as a result of
non-response or response of
ineligibility from ETC
recertification attempt
0 0 0 0 0
FCC Form 555
November 2014
Approved by OMB
3060-08 r 9
Section 3: De-enroll Percentage
Using the data entered in Section 2, complete the chart below toJind the percentage ofsubscribers de-enrolledfor this ETC.
M = (F+K)11= (J+L)O=((N+M)*t00)
Number ofsubscribers that the
ETC attempted to recertify directly
g through a state administrator,
ETC access to a state database, or
by USAC
(This should equal the number
reporled in Block E)
Number of subscribers
de-enrolled or
scheduled to be de-
enrolled as a result of
non-response or
ineligibiliS,
Percentage of subscribers
de-enrolled or scheduled to
be de-enrolled as a result of
ineligibility or non-response
33 5 15.160/o
Section 4: ETCs Subject to the Non-Usage Requirements
All ETCs must comolete the aDDroDriate check-box. ETCs that do not assess and collect a monthlv fee from their Lifeline subscribers are subiect to
the non-usage reqiirements.'ETCs subiect to the non-usage requirements must indicate the numbdr ofsubscribers"de-enrolled bv month in Section
4. ETCs thaT onli assess a fee but do n6t collect suchfeestrre s;tbject to the non-usage requirements dnd must also indicate the iumber of
subscribers de-dnrolled bi month.
Is the ETC subject to the non-usage requirements? Yes ftfl No Et
lfyes, record the number ofsubscribers de-enrolledfor non-usage by month in Block Q below.
P o
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 certifu 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
Steven Cowger/General
Manager/COO
Signature of Officer
[e-mail]
Printed Name and Title of Officer
0211512017
Email Address of Officer
Josie Simons
Date
208-326-4331
Person Completing This Certification Form Contact Phone Number
3