20170629Inland Telephone ETC Annual Report.pdf

Page 1
Page 1
FCC Form 481FCC Form 481 - Carrier Annual Reporting OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name: Person USAC should contact

<035>Contact Telephone Number:
<039>Contact Email Address:

Data Collection Form

Form Type

54.313 and 54.422
James K. Brooks
2018
[e-mail]
INLAND TEL-ID
5096492211 ext.
472423
Page 2
Page 2
(200) Service Outage Reporting (Voice)FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
<220>
NORS
Reference
Number
Outage Start
Date
Outage Start
Time
Outage End
Date
Outage End
Time
Number of
Customers Affected Total Number of
911 Facilities Service Outage Affect Multiple
Service Outage Preventative
<210>For the prior calendar year, were there any reportable voice service outages?
James K. Brooks
2018
[e-mail]
INLAND TEL-ID
5096492211 ext.
472423
No
(300) Unfulfilled Service Request FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
<300> Unfulfilled service request (voice)
<310> Detail on attempts (voice)
<320> Unfulfilled service request (broadband)
<330> Detail on attempts (broadband)
Name of Attached Document
Name of Attached Document
Page 3
Page 3
James K. Brooks
2018
[e-mail]
INLAND TEL-ID
5096492211 ext.
0
0
472423
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line
<030>
<039>Contact Email Address - Email Address of person identified in data line
<030>
<400>
Select from the drop-down list to indicate how you would like to report
voice complaints (zero or greater) for voice telephony service in the prior
calendar year for each service area in which you are designated an ETC for
any facilities you own, operate, lease, or otherwise utilize.
<410>Complaints per 1000 customers for fixed voice
<420>Complaints per 1000 customers for mobile voice
<430>
Select from the drop-down list to indicate how you would like to report
end-user customer complaints (zero or greater) for broadband service in
the prior calendar year for each service area in which you are designated
an ETC for any facilities you own, operate, lease, or otherwise utilize.
<440>
<450>
Complaints per 1000 customers for fixed broadband
Complaints per 1000 customers for mobile broadband
Page 4
Page 4
(400) Number of Complaints per 1,000 customers FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
James K. Brooks
2018
[e-mail]
0.0
Offered only fixed broadband
INLAND TEL-ID
5096492211 ext.
0.0
Offered only fixed voice
472423
(500) Compliance With Service Quality Standards and Consumer Protection Rules FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
Page 5
Page 5
<500> Certify compliance with applicable service quality standards and consumer protection rules
<510>Descriptive document for Service Quality Standards & Consumer Protection Rules Compliance
<515> Certify compliance with applicable minimum service standards
James K. Brooks
472423 ID 510 SERVICE QUALITY AND CPNI CERTIFICATION.pdf, 472423 ID 510
ITC CPNI PROCEDURES.pdf
Yes
2018
[e-mail]
INLAND TEL-ID
5096492211 ext.
472423
<010>
<015>
<020>
<030>
<035>
<039>
Study Area Code
Study Area Name
Program Year
Contact Name - Person USAC should contact regarding this data
Contact Telephone Number - Number of person identified in data line <030>
Contact Email Address - Email Address of person identified in data line <030>
(600) Functionality in Emergency Situations FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
<600> Certify compliance regarding ability to function in emergency situations
Page 6
<610>Descriptive document for Functionality in Emergency Situations
Page 6
James K. Brooks
2018
Yes
[e-mail]
472423 ID 610 FUNCTIONAL IN EMERGENCIES CERTIFICATION.pdf
INLAND TEL-ID
5096492211 ext.
472423
Page 7
Page 7
<701>Residential Local Service Charge Effective Date
<702>Single State-wide Residential Local Service Charge
<703>
State Exchange (ILEC)SAC (CETC)Rate Type
Residential Local
Service Rate Total per line Rates and Fees
Mandatory Extended Area
Service ChargeState Universal Service FeeState Subscriber Line Charge
(700) Price Offerings including Voice Rate Data FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
<010>
<015>
<020>
<030>
<035>
<039>
Study Area Code
Study Area Name
Program Year
Contact Name - Person USAC should contact regarding this data
Contact Telephone Number - Number of person identified in data line <030>
Contact Email Address - Email Address of person identified in data line <030>
James K. Brooks
1/1/2017
2018
-- See attached worksheet
--
[e-mail]
INLAND TEL-ID
5096492211 ext.
472423
Page 8
Page 8
<711>
Exchange (ILEC)Residential Rate
State Regulated
Broadband Service -
Download Speed Broadband Service -
Usage Allowance
Action Taken When
select}
<a1>
Usage Allowance
(710) Broadbrand Price Offerings FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
James K. Brooks
2018
[e-mail]
INLAND TEL-ID
5096492211 ext.
-- See attached
worksheet --
472423
Page 9
Page 9
(800) Operating Companies FCC Form 481
Data Collection Form OMB Control No. 3060-0986
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
<810>Reporting Carrier
<811>
<812>
<813>
Doing Business As Company or Brand Designation
<a1>
Affiliates
<a2>
SAC
<813>
Doing Business As Company or Brand Designation
<a1>
Affiliates
<a2>
SAC
<813>
Doing Business As Company or Brand Designation
<a1>
Affiliates
<a2>
SAC
<813>
Doing Business As Company or Brand Designation
<a1>
Affiliates
<a2>
SAC
/OMB Control No. 3060-0819
Western Elite Incorporated Services
James K. Brooks
Inland Telephone Company
2018
[e-mail]
Inland Telephone Company
INLAND TEL-ID
5096492211 ext.
-- See attached worksheet --
472423
Page 10
<910>Tribal Land(s) on which ETC Serves
<920>Tribal Government Engagement Obligation
<921>
<922>
<923>
<924>
<925>
<926>
<927>
<928>
<929>
(900) Tribal Lands Reporting FCC Form 481
Data Collection Form OMB Control No. 3060-0986
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
/OMB Control No. 3060-0819
Page 10
<900>Does the filing entity offer tribal land services? (Y/N)
James K. Brooks
472423 ID 920 TRIBAL ENGAGEMENT STATEMENT.pdf, 472423 ID 920 EAGLE RIVER-TRIBAL EXAMPLE.pdf
Yes
2018
[e-mail]
Yes
Yes
Yes
Yes
Yes
Nez Perce Reservation
Not Applicable
INLAND TEL-ID
Not Applicable
Yes
5096492211 ext.
Not Applicable
472423
Page 11
(1000) Voice and Broadband Service Rate Comparability FCC Form 481
Data Collection Form OMB Control No. 3060-0986
July 2013
/OMB Control No. 3060-0819
<1000> Voice services rate comparability certification
<1010> Attach detailed description for voice services rate
comparability compliance
Name of Attached Document
comparability compliance
Name of Attached Document
Page 11
James K. Brooks
472423 ID 1010 VOICE SERVICES COMPARABILITY CERTIFICATION.pdf
472423 ID 1030 BROADBAND SERVICES COMPARABILITY CERTIFICATION.pdf
2018
[e-mail]
Yes - Pricing is no more than the most recent applicable benchmark announced by
the Wireline Competition Bureau
INLAND TEL-ID
5096492211 ext.
Yes
472423
Page 12
Page 12
(1100) No Terrestrial Backhaul Reporting FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
<1130>
Certify whether terrestrial backhaul options exist (Y/N) <1100>
James K. Brooks
2018
[e-mail]
INLAND TEL-ID
5096492211 ext.
Yes
472423
Page 13
Page 13
(1200) Terms and Condition for Lifeline Customers FCC Form 481LifelineOMB Control No. 3060-0986/OMB Control No. 3060-0819Data Collection Form July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
<1210>Terms & Conditions of Voice Telephony Lifeline Plans
<1221>
<1222>
<1223>
<1220>Link to Public Website HTTP
telephony service plans offered to Lifeline subscribers,
Details on the number of minutes provided as part of the plan,
inlandnetworks.com
James K. Brooks
2018
[e-mail]
472423 ID 1210 INLAND LIFELINE APPLICATION.pdf, 472423 ID 1210 FCC FORM 555.pdf
INLAND TEL-ID
5096492211 ext.
4
4
4
472423
Page 14
Page 14
FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
(2005) Price Cap Carrier Additional Documentation
Data Collection Form
Including Rate-of-Return Carriers affiliated with Price Cap Local Exchange Carriers July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
July 2017 certification, this applies to Round 2 recipients of
Incremental Support.
<2022> Recipient certifies, representing year three after filing a notice of
acceptance of funding pursuant to 54.312(c), that the locations in
question are not receiving support under the Broadband Initiatives
Program or the Broadband Technology Opportunities Program for
projects that will provide broadband with speeds of at least 4
Mbps/1Mbps - 54.313(b)(2)(i). Round 2 recipients only.
<2023> The attachment on line 2024 includes a statement of the total amount of
capital funding expended in the previous year in meeting Connect
America Phase I deployment obligations, accompanied by a list of
census blocks indicating where funding was spent. This covers
year three - 54.313(b)(2)(ii). Round 2 recipients only.
<2024A> Round 2 Recipient of Incremental Support?
<2024B> Attach list of census blocks indicating where funding was spent in year
three - 54.313(b)(2)(ii). Round 2 recipients only.
Name of Attached Document Listing
Required Information
<2025A> Round 2 Recipient of Incremental Support?
<2025B> Attach geocoded Information for Phase I milestone reports (Round 2 for
year three) - Connect America Fund , WC Docket 10-90, Report and
Order, FCC 13-73, paragraph 35 (May 22, 2013).
Name of Attached Document Listing
Required Information
<2015> 2016 and future Frozen Support Certification 47 CFR § 54.313(c)(4)
Select the appropriate responses below (Yes, No, Not Applicable) to note compliance as a recipient of Incremental High Cost support, High Cost support to offset access charge
reductions, and Connect America Phase II support as set forth in 47 CFR § 54.313(b),(c),(d),(e). The information reported on this form and in the documents attached below is accurate.
Incremental Connect America Phase I reporting
<2011> 3rd Year Certification 47 CFR §54.313(b)(1)(ii) - Note that for the
James K. Brooks
2018
[e-mail]
INLAND TEL-ID
5096492211 ext.
472423
Page 15
FCC Form 481
OMB Control No. 3060-0986/OMB Control No. 3060-0819
(2005) Price Cap Carrier Additional Documentation
Data Collection Form
Including Rate-of-Return Carriers affiliated with Price Cap Local Exchange Carriers July 2013
Page 15
Price Cap Carrier Connect America ICC Support {47 CFR § 54.313(d)}
<2016> Certification support used to build broadband
Connect America Phase II Reporting {47 CFR § 54.313(e )}
<2017A> Connect America Fund Phase II recipient?
institutions to which the carrier newly began providing access to
broadband service in the preceding calendar year - 54.313(e)(1)(ii)(A)
Name of Attached Document Listing
Required Information
<2019> Recipient certifies that it bid on category one telecommunications and
Internet access services in response to all FCC Form 470 postings seeking
broadband service that meets the connectivity targets for the schools and
libraries universal service support program for eligible schools and
libraries located within any area in a census block where the carrier is
receiving Phase II model-based support, and that such bids were at rates
reasonably comparable to rates charged to eligible schools and libraries in
urban areas for comparable offerings - 54.313(e)(1)(ii)(C)
<2017C> Total amount of Phase II support, if any, the price cap carrier used for
capital expenditures in 2016.
<2018> Attach the number, names, and addresses of community anchor
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
Select from the drop down menu or check the boxes below to note compliance with 54.313(f)(1). Privately held carriers must ensure compliance with the
financial reporting requirements set forth in 47 CFR 54.313(f)(2). I further certify that the information reported on this form and in the documents
attached below is accurate.
Progress Report on 5 Year Plan
(3009) Carrier certifies to 54.313(f)(1)(iii)
(3010A)
(3010B) Name of Attached Document Listing Required
Information
(3012A)
(3012B) Name of Attached Document Listing Required
Information
(3013) (Yes/No)
(3014) (Yes/No)
(3015)
(3016)
(3017) Name of Attached Document Listing Required
Information
Please Provide Attachment
Community Anchor Institutions {47 CFR §
54.313(f)(1)(ii)}
Please Provide Attachment
Is your company a Privately Held ROR Carrier {47 CFR
§54.313(f)(2)}
If yes, does your company file the RUS annual report
Please check these boxes to confirm that the
attached PDF, on line 3017, contains the required
information pursuant to § 54.313(f)(2) compliance
requires:
Electronic copy of their annual RUS reports
(Operating Report for Telecommunications
Borrowers)
Document(s) with Balance Sheet, Income Statement
and Statement of Cash Flows
If the response is yes on line 3014, attach your
company's RUS annual report and all required
documentation
If the response is no on line 3014, is your company
audited?
If the response is yes on line 3018, please check the
boxes below to confirm your submission on line
3026 pursuant to § 54.313(f)(2), contains:
Either a copy of their audited financial statement; or
(2)a financial report in a format comparable to RUS
Operating Report for Telecommunications Borrowers
Document(s) for Balance Sheet, Income Statement
and Statement of Cash Flows
Management letter and/or audit opinion issued by
the independent certified public accountant that
performed the company’s financial audit.
If the response is no on line 3018, please check the
boxes below to confirm your submission on line
3026 pursuant to § 54.313(f)(2), contains:
Copy of their financial statement which has been
subject to review by an independent certified public
accountant; or 2) a financial report in a format
comparable to RUS Operating Report for
Telecommunications Borrowers
Underlying information subjected to a review by an
independent certified public accountant
Underlying information subjected to an officer
certification.
Document(s) with Balance Sheet, Income Statement
and Statement of Cash Flows
Attach the worksheet listing required information Name of Attached Document Listing Required
Information
page 16
(3005) Rate Of Return Carrier Additional Documentation FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
Page 16
Certification of Public Interest Obligations {47 CFR §
54.313(f)(1)(i)}
4
James K. Brooks
4
2018
[e-mail]
Yes - Attach Certification
472423 ID 3010b BROADBAND MILESTONE
CERTIFICATION.pdf
INLAND TEL-ID
5096492211 ext.
472423 ID 3017 INLAND RUS OPERATING STATEMENT.pdf
472423
No - No New Community Anchors
Page 17
Page 17
(3005) Rate Of Return Carrier Additional Documentation (Continued)FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
Financial Data Summary
(3027) Revenue
(3028) Operating Expenses
(3029) Net Income
(3030) Telephone Plant In Service(TPIS)
(3031) Total Assets
(3032) Total Debt
(3033) Total Equity
(3034) Dividends
37510983
James K. Brooks
2018
[e-mail]
4717801
323316
INLAND TEL-ID
6432242
24163855
5096492211 ext.
5585720
14428319
472423
0
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
4005 Rural Broadband Experiment
Authorized Rural Broadband Experiment (RBE) recipients must address the certification for public interest obligations, provide a list of newly served
community anchor institutions, and provide a list of locations where broadband has been deployed.
Public Interest Obligations – FCC 14-98 (paragraphs 26-29, 78)
4001
interest obligations consistent with the category for which they were selected, including broadband speed,
latency, usage capacity, and rates that are reasonably comparable to rates for comparable offerings in urban
Community Anchor Institutions – FCC 14-98 (paragraph 79)
4003a
which they newly deployed broadband service in the preceding calendar year. On this line, please respond
If yes to 4003A, please provide a response for 4003B.
4003b
of community anchor institutions to which the
recipient newly began providing access to
Broadband Deployment Locations – FCC 14-98 (paragraph 80)
4004a
which broadband has been deployed as of the
June 1st immediately preceding the July 1st filing Name of Attached Document Listing Required Information
4004b
recipient is meeting the relevant public service
obligations for the identified locations. Materials
must at least detail the pricing, offered broadband
speed and data usage allowances available in the
Name of Attached Document Listing Required Information
FCC Form 481 (4005) Rural Broadband Experiment Additional Documentation OMB Control No. 3060-0986/OMB Control No. 3060-0819 Data Collection Form
July 2013
page 18
Page 18
James K. Brooks
2018
[e-mail]
INLAND TEL-ID
5096492211 ext.
472423
Page 19
Page 19
Certification - Reporting Carrier FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
TO BE COMPLETED BY THE REPORTING CARRIER, IF THE REPORTING CARRIER IS FILING ANNUAL REPORTING ON ITS OWN BEHALF:
Printed name of Authorized Officer:
Certification of Officer as to the Accuracy of the Data Reported for the Annual Reporting for CAF or LI Recipients
Name of Reporting Carrier:
Signature of Authorized Officer:Date
I certify that I am an officer of the reporting carrier; my responsibilities include ensuring the accuracy of the annual reporting requirements for universal service support
recipients; and, to the best of my knowledge, the information reported on this form and in any attachments is accurate.
Title or position of Authorized Officer:
Telephone number of Authorized Officer:
Study Area Code of Reporting Carrier:Filing Due Date for this form:
Persons willfully making false statements on this form can be punished by fine or forfeiture under the Communications Act of 1934, 47 U.S.C. §§ 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. § 1001.
CERTIFIED ONLINE
07/03/2017
5096492211 ext.
James K. Brooks
James Brooks
2018
06/28/2017
[e-mail]
INLAND TEL-ID
Treasurer/Controller
INLAND TEL-ID
5096492211 ext.
472423
472423
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Page 20
Certification - Agent / Carrier FCC Form 481Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
Certification of Agent Authorized to File Annual Reports for CAF or LI Recipients on Behalf of Reporting Carrier
TO BE COMPLETED BY THE AUTHORIZED AGENT:
Telephone number of Authorized Agent or Employee of Agent:
Signature of Authorized Agent or Employee of Agent:
Name of Authorized Agent Firm:
I, as agent for the reporting carrier, certify that I am authorized to submit the annual reports for universal service support recipients on behalf of the reporting carrier; I have provided
the data reported herein based on data provided by the reporting carrier; and, to the best of my knowledge, the information reported herein is accurate.
Date:
Name of Authorized Agent Employee:
TO BE COMPLETED BY THE REPORTING CARRIER, IF AN AGENT IS FILING ANNUAL REPORTS ON THE CARRIER'S BEHALF:
Certification of Officer to Authorize an Agent to File Annual Reports for CAF or LI Recipients on Behalf of Reporting Carrier
I certify that (Name of Agent)_______________________________________________________ is authorized to submit the information reported on behalf of the reporting carrier. I
also certify that I am an officer of the reporting carrier; my responsibilities include ensuring the accuracy of the annual data reporting requirements provided to the authorized
agent; and, to the best of my knowledge, the reports and data provided to the authorized agent is accurate.
Date:
Name of Authorized Agent:
Signature of Authorized Officer:
Persons willfully making false statements on this form can be punished by fine or forfeiture under the Communications Act of 1934, 47 U.S.C. §§ 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. § 1001.
Persons willfully making false statements on this form can be punished by fine or forfeiture under the Communications Act of 1934, 47 U.S.C. §§ 502, 503(b), or fine or imprisonment under Title
18 of the United States Code, 18 U.S.C. § 1001.
James K. Brooks
2018
[e-mail]
INLAND TEL-ID
5096492211 ext.
472423
Attachments
(700) Price Offerings including Voice Rate Data FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
<701>Residential Local Service Charge Effective Date
<702>Single State-wide Residential Local Service Charge
<703>
State Exchange (ILEC)SAC (CETC)Rate Type
Residential Local
Service Rate Total per line Rates and Fees
Mandatory Extended Area
Service ChargeState Universal Service FeeState Subscriber Line Charge
James K. Brooks
1/1/2017
25.88
18.12
18.12
25.88
2018
[e-mail]
0.0
LEON
LEON
LENORE
LENORE
0.0
0.0
0.0
INLAND TEL-ID
ID
ID
ID
ID
MS
FR
MS
5096492211 ext.
FR
0.0
0.0
0.0
0.0
18.0
25.76
25.76
18.0
0.12
0.12
472423
0.12
0.12
(710) Broadband Price Offerings FCC Form 481
Data Collection Form OMB Control No. 3060-0986/OMB Control No. 3060-0819
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>

<711>
State Exchange Residential State Regulated Broadband Service -
Download Speed
(Mbps)

Other, Warning call/Alert
Other, Warning call/Alert
Other, Warning call/Alert
Other, Warning call/Alert
Other, Warning call/Alert
Other, Warning call/Alert
Other, Warning call/Alert
Other, Warning call/Alert
Other, Warning call/Alert
Other, Warning call/Alert
James K. Brooks
210.0
220.0 1.0
1.0
ID
ID
ID
ID
ID
ID
ID
2018
ID
ID
ID
[e-mail]
500.0
500.0
500.0
500.0
500.0
500.0
500.0
500.0
500.0
500.0
LEON DATA ONLY
LEON
LEON
LENORE DATA ONLY
LEON
LENORE DATA ONLY
LENORE DATA ONLY
LENORE
LENORE
LENORE
Other, Warning call/Alert
Other, Warning call/Alert10.0
INLAND TEL-ID
6.0
5096492211 ext.
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59.95
75.0
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75.0
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ID
ID
LEON DATA ONLY
LEON DATA ONLY
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<813><a3>
Doing Business As Company or Brand Designation
<a1>
Affiliates
<a2>
SAC
(800) Operating Companies FCC Form 481
Data Collection Form OMB Control No. 3060-0986
July 2013
<010>Study Area Code
<015>Study Area Name
<020>Program Year
<030>Contact Name - Person USAC should contact regarding this data
<035>Contact Telephone Number - Number of person identified in data line <030>
<039>Contact Email Address - Email Address of person identified in data line <030>
<810>Reporting Carrier
<811>
<812>
/OMB Control No. 3060-0819
Western Elite Incorporated Services
James K. Brooks
Inland Telephone Company
2018
Inland Telephone Company or Inland Networks
[e-mail]
Inland Telephone Company
INLAND TEL-ID
5096492211 ext.
Inland Telephone Company
472423
522423
INLAND TELEPHONE COMPANY ‐ SAC 472423 ID
ATTACHMENTS TO THE FCC FORM 481
LINE 510 ‐ COMPLIANCE WITH SERVICE QUALITY STANDARDS AND 
CONSUMER PROTECTION RULES
(472423 ID 510 SERVICE QUALITY AND CPNI CERTIFICATION.pdf
(472423 ID 510 ITC CPNI PROCEDURES.pdf
1

STATEMENT REGARDING OPERATING PROCEDURES
IMPLEMENTING 47 C.F.R. PART 64 SUBPART U
GOVERNING USE OF
CUSTOMER PROPRIETARY NETWORK INFORMATION (CPNI)
MARCH 1, 2017

The following statement explains how the operating procedures of Inland Telephone
Company (“Inland” or “Company”) ensure that it is in compliance with the Commission’s CPNI
rules, as codified at 47 C.F.R. Part 64 Subpart U (§§ 64.2001-64.2011) and is relevant to
calendar year 2016. Except as otherwise indicated, the following applies with respect to the
Commission’s rules in effect both before and after the December 8, 2007 effective date of the
Commission’s April 2, 2007 Report and Order in CC Docket No. 96-115. See FCC 07-22 (rel.
Apr. 2, 2007); Public Notice, DA 07-4915 (rel. Dec. 6, 2007). This statement covers calendar
year 2016.
I. Use of customer proprietary network information without customer approval.
A. Inland may use, disclose, or permit access to CPNI for the purpose of providing or
marketing service offerings among the categories of service to which the customer already
subscribes from Inland, without customer approval.
B. Inland may not use, disclose, or permit access to CPNI to market to a customer,
service offerings that are within a category of service to which the subscriber does not already
subscribe from Inland, unless Inland has customer approval to do so, except as described in
Section I.C.
(1) Inland may use, disclose or permit access to CPNI derived from their
provision of local exchange service or interexchange service, without customer approval,
for the provision of CPE and information services, such as call answering, voice mail or
messaging, voice storage and retrieval services, and fax storage and retrieval services.
(2) Inland may not use, disclose or permit access to CPNI to identify or track
customers that call competing service providers except for CPNI made available to other
telecommunications carriers pursuant to tariffed or detariffed billing and collection
arrangements and billing and collection services provided pursuant thereto. The
Company does not sell CPNI to any third-party for any purpose.
C. Inland may use, disclose, or permit access to CPNI, without customer approval, as
follows:
(1) Inland may use, disclose, or permit access to CPNI, in its provision of
inside wire installation, maintenance, and repair services.
(2) Inland may use CPNI to market services formerly known as adjunct-to-
basic services, such as, but not limited to, speed dialing, computer-provided directory
2
assistance, call monitoring, call tracing, call blocking, call return, repeat dialing, call
tracking, call waiting, caller I.D., call forwarding, and certain Centrex features.
D. Inland may use, disclose, or permit access to CPNI to protect Inland’s rights or
property; to protect its users and other carriers from fraudulent, abusive, or unlawful use of, or
subscription to, Inland’s services; and to render, provision, bill or collect for services.
Inland provides local exchange telephone service and access to long distance service
providers in six exchanges in the states of Idaho and Washington. Inland’s operating
procedures comply with the above requirements and include, but are not limited to, the
provisions described below. The Company does not engage in any outbound telemarketing.
Outbound print marketing, if any, that may be distributed by the Company by mail is
addressed to all subscribers or customers within the applicable geographic area, zip code(s)
and/or telephone number prefix(es), without regard to the specific services that the subscriber
or customer receives, or does not receive, from the Company and/or the Company’s affiliates.
Under Company policy, none of the Company’s affiliates is permitted to use any CPNI of the
Company for any outbound telemarketing or outbound print marketing.
Moreover, the Company does not use any CPNI for any inbound marketing of services
that are not within a category of service (i.e., local and interexchange) to which the customer
already subscribes from the Company and/or one or more of the Company’s affiliates. The
Company does not sell, or provide access to any third party to, any of the Company’s CPNI for
purposes of marketing the services of the Company or of any of its affiliates, other than as
permitted without prior customer approval with respect to the Company’s affiliates. Except for
CPNI made available to other telecommunications carriers pursuant to tariffed or detariffed
billing and collection arrangements and billing and collection services provided pursuant
thereto, and pursuant to Commission-mandated carrier change procedures, the Company does
not provide CPNI to any third-party for any purpose.

The Company, its employees and agents may make such other uses and disclosures of,
and permit access to, CPNI without customer approval as are permitted by applicable statute,
rule, regulation or order. Such uses, disclosures or access may include those authorized by
Sections 222(c) and (d) of the Communications Act of 1934, as amended, by Section 64.2005
of the Commission’s rules and by orders of the Commission.

Except as set forth above, the Company does not provide any CPNI to any
governmental entity, or to any other third party, other than: pursuant to subpoena or other
lawful process or with the subscriber’s prior written consent, or in accordance with the
authentication and other requirement described at Section IV below and in the FCC’s rules,
as a result of a person representing himself or herself to be the subscriber (or the subscriber’s
duly authorized agent) and having confirmed his or her identity or authority by providing to
the Company appropriate identifying information (such as Social Security Number, driver’s
license number, mother’s maiden name, user name or password, as appropriate or otherwise
required).

3
II. Approval required for use of customer proprietary network information.
A. Inland may obtain customer approval through written, oral or electronic methods.
(1) Inland does not seek or obtain oral approval, and therefore does not bear
the burden of demonstrating that such approval has been given in compliance with the
FCC’s rules.
(2) A customer’s approval or disapproval obtained by Inland to use, disclose,
or permit access to the customer’s CPNI, the use of CPNI outside of the customer’s total
service relationship with Inland must remain in effect until the customer revokes or limits
such approval or disapproval.
(3) Inland must maintain records of notification and approval, whether oral,
written or electronic, for at least one year.
B. Use of Opt-Out and Opt-In Approval Processes.
(1) Except where use, disclosure, or access to CPNI is otherwise permitted
without prior customer approval (as described above), Inland only uses, discloses or
permits access to CPNI upon opt-out or opt-in approval, consistent with Section 64.2007
of the Commission’s rules and, by December 8, 2007, with the Commission’s amended
rules. Inland’s process is described in Section II.A above.
(2) Except for use and disclosure of CPNI that is permitted without customer
approval under Section I, or that is described Section II.B, or as otherwise provided in
section 222 of the Communications Act of 1934, as amended, Inland may only use,
disclose, or permit access to its customer’s individually identifiable CPNI subject to opt-
in approval.
The Company currently does not use CPNI in a manner that requires prior
customer approval. Should Inland’s policy change, however, Inland shall implement
the foregoing policies to ensure the FCC’s rules are complied with.
III. Notice required for use of customer proprietary network information.
A. Notification, Generally.
(1) Prior to any solicitation for customer approval, Inland must provide
notification to the customer of the customer’s right to restrict use of, disclosure of, and
access to that customer’s CPNI.
(2) Inland must maintain records of notification, whether oral, written or
electronic, for at least one year.
B. Individual notice to customers must be provided when soliciting approval to use,
disclose, or permit access to customers’ CPNI.
4
C. Content of Notice.
Customer notification must provide sufficient information to enable the customer to make
an informed decision as to whether to permit Inland to use, disclose, or permit access to, the
customer’s CPNI.
(1) The notification must state that the customer has a right, and Inland has a
duty, under federal law, to protect the confidentiality of CPNI.
(2) The notification must specify the types of information that constitute
CPNI and the specific entities that will receive the CPNI, describe the purposes for which
CPNI will be used, and inform the customer of his or her right to disapprove those uses,
and deny or withdraw access to CPNI at any time.
(3) The notification must advise the customer of the precise steps the
customer must take in order to grant or deny access to CPNI, and must clearly state that a
denial of approval will not affect the provision of any services to which the customer
subscribes. However, Inland may provide a brief statement, in clear and neutral language,
describing consequences directly resulting from the lack of access to CPNI.
(4) The notification must be comprehensible and must not be misleading.
(5) If written notification is provided, the notice must be clearly legible, use
sufficiently large type, and be placed in an area so as to be readily apparent to a customer.
(6) If any portion of a notification is translated into another language, then all
portions of the notification must be translated into that language.
(7) Inland may state in the notification that the customer’s approval to use
CPNI may enhance Inland’s ability to offer products and services tailored to the
customer’s needs. Inland also may state in the notification that it may be compelled to
disclose CPNI to any person upon affirmative written request by the customer.
(8) Inland may not include in the notification any statement attempting to
encourage a customer to freeze third-party access to CPNI.
(9) The notification must state that any approval or denial of approval for the
use of CPNI outside of the service to which the customer already subscribes from Inland
is valid until the customer affirmatively revokes or limits such approval or denial.
(10) Inland’s solicitation for approval must be proximate to the notification of a
customer’s CPNI rights.
D. Notice Requirements Specific to Opt-Out.
Inland must provide notification to obtain opt-out approval through electronic or written
methods, but not by oral communication (except as provided in paragraph F of this section). The
5
contents of any such notification must comply with the requirements of paragraph C of this
section.
(1) Inland must wait a 30-day minimum period of time after giving customers
notice and an opportunity to opt-out before assuming customer approval to use, disclose,
or permit access to CPNI. Inland may, in its discretion, provide for a longer period.
Inland must notify customers as to the applicable waiting period for a response before
approval is assumed.
(i) In the case of an electronic form of notification, the waiting period
shall begin to run from the date on which the notification was sent; and
(ii) In the case of notification by mail, the waiting period shall begin to
run on the third day following the date that the notification was mailed.
(2) Insofar as Inland is using the opt-out mechanism, it must provide a Notice
to its customers every two years.
(3) If Inland uses e-mail to provide opt-out notices, it must comply with the
following requirements in addition to the requirements generally applicable to
notification:
(i) Inland must obtain express, verifiable, prior approval from
consumers to send notices via e-mail regarding its service in general, or CPNI in
particular;
(ii) Inland must allow customers to reply directly to e-mails containing
CPNI notices in order to opt-out;
(iii) Opt-out e-mail notices that are returned to Inland as undeliverable
must be sent to the customer in another form before Inland may consider the
customer to have received notice;
(iv) Inland must ensure that the subject line of the message clearly and
accurately identifies the subject matter of the e-mail; and
(v) Inland must make available to every customer a method to opt-out
that is of no additional cost to the customer and that is available 24 hours a day,
seven days a week. Inland may satisfy this requirement through a combination of
methods, so long as all customers have the ability to opt-out at no cost and are
able to effectuate that choice whenever they choose.
E. Notice Requirements Specific to Opt-In.
Inland may provide notification to obtain opt-in approval through oral, written, or
electronic methods. The contents of any such notification must comply with the requirements of
paragraph C of this section.
6
F. Notice Requirements Specific to One-Time Use of CPNI.
(1) Inland may use oral notice to obtain limited, one-time use of CPNI for
inbound and outbound customer telephone contacts for the duration of the call, regardless
of whether Inland uses opt-out or opt-in approval based on the nature of the contact.
(2) The contents of any such notification must comply with the requirements
of paragraph C of this section, except that Inland may omit any of the following notice
provisions if not relevant to the limited use for which Inland seeks CPNI:
(i) Inland need not advise customers that if they have opted-out
previously, no action is needed to maintain the opt-out election;
(ii) Inland need not advise customers that they may share CPNI with
their affiliates or third parties and need not name those entities, if the limited
CPNI usage will not result in use by, or disclosure to, an affiliate or third party;
(iii) Inland need not disclose the means by which a customer can deny
or withdraw future access to CPNI, so long as Inland explains to customers that
the scope of the approval Inland seeks is limited to one-time use; and
(iv) Inland may omit disclosure of the precise steps a customer must
take in order to grant or deny access to CPNI, as long as Inland clearly
communicates that the customer can deny access to his CPNI for the call.
The Company currently does not use CPNI in a manner that requires prior
customer approval. Should Inland’s policy change, however, Inland shall implement
the foregoing policies to ensure the FCC’s rules are complied with.
IV. Safeguards required for use and disclosure of customer proprietary network
information.
A. Inland must implement a system by which the status of a customer’s CPNI
approval can be clearly established prior to the use of CPNI. Inland’s policies and procedures
are detailed in Section II above.
B. Effective December 8, 2007, Inland may release call detail information during a
customer initiated telephone contact only if reasonable authentication procedures are complied
with and (1) the customer provides Inland with a pre-established password, (2) Inland, at the
customer’s request, sends the call detail information to the customer’s address of record provided
the address of record has been associated with the account for at least thirty (30) days, or (3)
when Inland calls the telephone number of record to disclose the call detail information. Inland
is permitted to create a back-up customer authentication method for lost or forgotten passwords.
Inland is also prohibited from releasing call detail information during a retail visit without the
appropriate password or valid photo identification.
However, if the during a customer-initiated telephone contact, the customer is able to
provide without assistance from Inland personnel all of the call detail information necessary to
7
address a customer service issue (i.e., the telephone number called, when it was called, and if
applicable the amount charged for the call), then Inland personnel are permitted to proceed with
its routine customer care procedures.
C. Not later than June 8, 2008, Inland must authenticate a customer without readily
available biographical or account information prior to allowing the customer on-line access to
CPNI related telecommunication service account. Once authenticated, the customer may only
obtain on-line access to CPNI related telecommunications service account through a password.
D. Effective December 8, 2007, Inland is required to notify customers immediately
when a password or back-up means of authentication for lost or forgotten passwords, on-line
account, or address of record is created or changed. Such notification is not required when the
customer initiates service, including the selection of a password.
E. Business customers are exempt from the password requirements which became
effective December 8, 2007, if: the customer is contractually bound to Inland, is serviced by a
dedicated Inland account representative as the primary contact, and within the contract Inland is
responsible to address its CPNI obligations. If, at any point, the business customer must go
through a call center to reach a customer service representative, then the exemption does not
apply.
F. Inland trains its personnel as to when they are and are not authorized to use CPNI,
and Inland must have an express disciplinary process in place.
G. Inland must maintain a record, electronically or in some other manner, of its own
and its affiliates’ sales and marketing campaigns that use its customers’ CPNI. Inland shall
maintain a record of all instances where CPNI was disclosed or provided to third parties, or
where third parties were allowed access to CPNI. The record must include a description of each
campaign, the specific CPNI that was used in the campaign, and what products and services were
offered as a part of the campaign. Inland shall retain the record for a minimum of one year.
H. Inland must establish a supervisory review process regarding its compliance with
the FCC’s CPNI rules for outbound marketing situations and maintain records of its compliance
for a minimum period of one year. Specifically, sales personnel must obtain supervisory
approval of any proposed outbound marketing request for customer approval.
I. Effective December 8, 2007, Inland must take reasonable measures to discover and
protect against attempts to gain unauthorized access to CPNI, which may include encryption of
its databases. Inland must properly authenticate a customer prior to disclosing CPNI based on a
customer-initiated telephone contact, on-line account access, or an in-store visit.
Inland must take measures to protect CPNI stored in its internal databases from potential
unauthorized access, and evaluate and increase its security measures should it discover an
increase in attempts to gain access to unauthorized information.
J. Inland must provide written notice within five business days to the FCC of any
instance where the opt-out mechanisms do not work properly, to such a degree that consumers’
inability to opt-out is more than an anomaly.
8
(1) The notice shall be in the form of a letter, and shall include Inland’s name,
a description of the opt-out mechanism(s) used, the problem(s) experienced, the remedy
proposed and when it will be/was implemented, whether the relevant state commission(s)
has been notified and whether it has taken any action, a copy of the notice provided to
customers, and contact information.
(2) Such notice must be submitted even if Inland offers other methods by
which consumers may opt-out.
K. Effective December 8, 2007, Inland has a general duty to first inform federal law
enforcement agencies, followed up by notification to affected customers, after reasonable
determination of a breach of its customers’ CPNI.
(1) Inland must file an electronic notification to the United States Secret Service
(USSS) and the Federal Bureau of Investigation (FBI) within seven (7) business days
through the central reporting facility furnished by the Commission.
(2) Inland is prohibited from notifying customers or the general public of the
breach until seven (7) business days have passed after notification to the USSS and FBI
unless under certain specified circumstances: (a) Inland identifies an “extraordinary need
to notify customers” before that period or (b) An ongoing or potential investigation or
national security requires customer disclosure to be potentially delayed for up to thirty
(30) days. Inland must notify the affected customer(s) after the applicable period.
(3) Inland must maintain a record, whether electronically or in some other manner of
any breaches discovered, notifications made to the USSS or FBI and notifications made
to customers. The record must include, if available, dates of discovery and notification, a
detailed description of the CPNI that was the subject of the breach, and the circumstances
of the breach. Records must be maintained for a two (2) year period.
Inland’s operating procedures comply with all of the above requirements, including
those that became effective December 8, 2007. With respect to online authentication in
particular, Inland implemented measures to ensure compliance by the applicable June 8, 2008
deadline. As previously discussed, the Company currently does not use CPNI in a manner
that requires prior customer approval. Should Inland’s policy change, however, Inland shall
implement the relevant aforementioned policies to ensure the FCC’s rules are complied with.
Inland notes in particular that:
 Company personnel are trained as to when they are and are not authorized to use
CPNI, and that an express process is in place such that violations of these procedures
may result in disciplinary action, up to and including termination of employment.
 Inland does not provide customers’ with online access to their CPNI at this time.
 With respect to business customers subject to Section IV.E above, Inland requires them
to provide the names of all that are authorized to have access to the account and at
what authorization level (e.g. to make service changes, request additional services,
9
billing inquiries) and further requires that a 6 to 10-place alphanumeric password be
established.
 Operating procedures have been implemented to comply with the remaining
requirements described above and applicable to Inland’s use, disclosure of and third
party access to CPNI.
V. Supplemental Information
Effective December 8, 2007, the FCC’s rules require that the annual certification filed
pursuant to 47 C.F.R. § 64.2009(e) disclose any actions taken against data brokers and a
summary of all consumer complaints received in the previous calendar year regarding the
unauthorized release of CPNI. Inland is not aware of any consumer complaints regarding the
unauthorized release of CPNI and has not taken action against any data brokers.
As of January 3, 2017, telecommunications carriers no longer are subject to the specific
recordkeeping and annual CPNI compliance certification requirements contained in Sections
64.2009(c) and (e) of the Commission’s rules however, the Inland maintains these procedures.

LINE 610 ‐ FUNCTIONALITY IN EMERGENCY SITUATIONS
(472423 ID 610 FINCTIONAL IN EMERGENCIES CERTIFICATION.pdf
LINE 920 ‐ TRIBAL GOVERNMENT ENGAGEMENT OBLIGATION
(472423 ID 920 TRIBAL ENGAGEMENT STATEMENT.pdf)
(472423 ID 920 EAGLE RIVER‐TRIBAL EXAMPLE.pdf
LINE 920 

TRIBAL ENGAGEMENT STATEMENT

Although the Lenore exchange service area of Inland Telephone
Company, Study Area Code 472423, is within the conventional boundaries of
the Nez Perce Tribe reservation, the exchange primarily consists of private
property (non-tribal owned). The Company did not perform a needs
assessment, deployment planning, feasibility, or sustainability planning with a
focus on Tribal community anchor institutions since the Company does not
serve the areas in which the Nez Perce have their tribal headquarters,
administration, enterprises, cultural center, hatchery, or any anchor
institutions.

As for subscribers, the Company would not know if a subscriber was a
tribal member unless they were claiming Tribal Lifeline. Inland Telephone
Company is an equal opportunity provider and does not ask or keep track of
race, creed, color or sexual orientation when providing service; to keep track of
this information may be considered profiling which the Company does not
engage in.

The Company fully cooperates with the Nez Perce Tribe in matters
involving easements, rights of way and any build that may require the possible
disturbance of tribal ground; potential archeological study whether the ground
is tribally owned or not.

Attached is a copy of correspondence from a contractor, Eagle River
Development LLC, contracted by the Company to perform a study compliant to
the National Environmental Policy Act for a proposed tower site. The study
demonstrates that although the proposed tower site is not on tribal owned
property, the Company seeks Section 106 concurrence from the Nez Perce
Tribe as it is located within the traditional boundaries of the Nez Perce
Reservation.

LINE 1010 ‐ VOICE SERVICE RATE COMPARABILITY COMPLIANCE
(472423 ID 1010 VOICE SERVICES COMPARABILITY CERTIFICATION.pdf
LINE 1030 ‐ BROADBAND COMPARABILITY COMPLIANCE
(472423 ID 1030 BROADBAND SERVICES COMPARABILITY CERTIFICATION.pdf
LINE 3010B ‐ CERTIFICATE OF PUBLIC INTEREST {47 CFR § 
54.313(f)(1)(i)}
(472423 ID 3010B BROADBAND MILESTONE CERTIFICATION.pdf)
LINE 1210 ‐ TERMS & CONDITIONS OF VOICE TELEPHONY LIFELINE 
PLANS 
(472423 ID 1210 INLAND LIFELINE APPLICATION.pdf
(472423 ID 1210 FCC FORM 555.pdf
“Your Hometown Connection”
(an Inland Networks Family Company)

LIFELINE ASSISTANCE
From Inland Telephone Company
Do you qualify for discounted monthly telephone
service?

Lifeline Discounts
Inland Telephone Company (d/b/a Inland Networks) customers may be eligible to currently save $9.25 per
month through the Federal Lifeline Program and, for Idaho residents, an additional $2.50 per month through
the Idaho Telecommunications Service Assistance Program (ITSAP), administered through the Community
Action Partnership Association of Idaho (CAPAI).

Qualifying for Federal Lifeline
Customers may qualify for Federal Lifeline
assistance if they are currently participating in one
or more of the following assistance programs:

 Medicaid
 Supplemental Security Income (SSI)
 Temporary Assistance for Needy Families
(TANF)
 Federal Public Housing Assistance (FPHA)
or Section 8
 Supplemental Nutrition Assistance Program
(SNAP)(Food Stamps)
 Low Income Home Energy Assistance
Program (LIHEAP)
 National School Lunch Program’s Free
Lunch Program

Additionally, customers may qualify for Federal
Lifeline if their total household income is at or
below 135% of the Federal Poverty Guideline.

Customers who are also residents of federally
recognized Tribal Lands may qualify for additional
Federal Lifeline support of up to $25 per month
and may qualify for Lifeline under the assistance
programs listed above or if they currently
participate in one or more of the following
assistance programs:

 Bureau of Indian Affairs General Assistance
 Tribally Administered Temporary
Assistance for Needy Families (TTANF)
 Head Start (must satisfy income qualifying
standard)
 Food Distribution Program on Indian
Reservations (FDPIR)

Signing-Up for Lifeline Service
If you believe that you may qualify for Federal
assistance, you must complete an application that
can be obtained from a Customer Service
Representative at 1-800-462-4578.

For State assistance, Inland Telephone Company
still asks that you complete an application
however, qualifying for State assistance must be
done through the applicable State agency; CAPAI
for Idaho residents.

Additional Information
For additional information about the Federal
Lifeline program, please visit www.usac.org/li .

Important Information
Lifeline assistance is a government assistance
program that provides only eligible consumers with
discounted service that is non-transferable and is
available for only one discount per household. A
household is defined, for purposes of the Lifeline
program, as any individual or group of individuals
living at the same address that share income and
expenses. The Lifeline assistance is only available
in areas where the company has Eligible
Telecommunications Carrier status. The Federal
Communications Commission has mandated that
all recipients of Federal Lifeline certify their
eligibility annually.
City: State:
City: State:
PLEASE CHECK the corresponding box for the number of household members.
1 5 $38,394
2 6 $43,983
3 7 $49,586
4 8 $55,202
# $5,616
Tribal Identification Number:
INLAND TELEPHONE COMPANY
I certify that I qualify for Lifeline Support and am currently participating in one or more of the programs listed that I have checked below and am 
providing a copy of my benefit or program participation card or award letter. (Please check all applicable boxes)
I certify that my household income is at or below 135% of the federal poverty guidelines and therefore I qualify for Lifeline Support under 
the federal income requirements and have provided proof of my qualifications.
Telephone Number:Customer Name:
Date of Birth:
Service Address:
Billing Address:
CERTIFICATION BY CUSTOMER IN ORDER TO RECEIVE FEDERAL LIFELINE SUPPORT
[phone]; [phone]
Fax: [phone]
Email: [e-mail]
Please respond completely. Inaccurate or incomplete responses may cause your application to be rejected.  Information provided should be that 
of the account holder.
103 S. 2ND Street
P.O. Box 171
Roslyn, WA 98941
Last 4 Digits of Social Security Number:
FEDERAL PROGRAM ELIGIBILITY (DOCUMENTATION REQUIRED)
Supplemental Nutrition Assistance Program 
(SNAP)(f/k/a Food Stamps)
Federal Public Housing Assistance (FPHA)
Medicaid
Veterans Pension and Survivors Benefit
$21,627
$16,038
INCOME ELIGIBILITY (DOCUMENTATION REQUIRED)
$27,216
$32,805
NOTE: THE ABOVE AMOUNTS ARE 2016 FEDERAL POVERTY LEVELS; SUBJECT TO CHANGE ANNUALLY.
If I qualify for Federal Lifeline Support, I would like the Lifeline Support to be applied to my (Please select one):
Telephone Service Internet Service (Must suscribe to at least a 10/1 service level)
Bureau of Indian Affairs General Assistance
Head Start (Income eligible)
Food Distribution Program on Indian Reservations (FDPIR)
Income Eligibility (See above Income Eligibility)
For each additional household member add # of Additional:
I certify that I qualify for tribal Lifeline Support, as I reside on land that meets the Bureau of Indian Affairs definition of "reservation" (any federally 
recognized Indian tribe's reservation, Pueblo, or Colony including former reservations in Oklahoma, Alaska Native regions, Hawaiian Home Lands 
and Indian Allotments) AND participate in one or more of the programs listed that I have checked below and am providing a copy of my benefit or 
program participation card or award letter. (Please check all applicable boxes)
Federal Public Housing Assistance (FPHA)
Supplemental Security Income (SSI)
Tribal Administered Temporary Assistance for Needy Families 
(TTANF)
Medicaid
Veterans Pension and Survivors Benefit
TRIBAL LIFELINE ELIGIBILITY (DOCUMENTATION REQUIRED)
Supplemental Security Income (SSI)
Supplemental Nutrition Assistance Program 
(SNAP)(f/k/a Food Stamps)
SUBSCRIBER CERTIFICATION
It is understood that by participating in the Lifeline program, the support that I receive is not actual payment to me but a discount on my monthly 
billed service.  Participating in Lifeline does not protect me from collection procedures if I do not pay my telephone or Internet bill.  I fully 
understand that this discount, as well as the criteria for participation in the Lifeline Program, may change and I may no longer qualify, or the 
amount of support may increase or decrease.
Filename: 161025 LIFELINE CERTIFICATION FORM.xlsx LIFELINE CERTIFICATION Page 1 of 3
INLAND TELEPHONE COMPANY
[phone]; [phone]
Fax: [phone]
Email: [e-mail]
103 S. 2ND Street
P.O. Box 171
Roslyn, WA 98941
DATE
Inland Telephone Company will keep the information contained in this form confidential, except as required by federal or state law. ALL INFORMATION 
COMPLETED ON THIS FORM IS SUBJECT TO STATE AND FEDERAL PERJURY PENALTIES.
SIGNATURE OF APPLICANT
I certify that the information provided on this form is true and correct to the best of my knowledge under penalty of perjury and if I have provded 
any misleading statements in order to receive support, I will be liable for any support received, my service may be discontinued, it may result in de‐
enrollment and my being barred from the program and I would be subject to state and federal fines and imprisonment.
As the Certifying Subscriber, I certify that, (i) the service is for me and not a member of the household; (ii) I am not listed as a dependent on 
someone else’s tax return; and, (iii) the service address is my primary residence.  I further certify that the service that I receive from Inland 
Telephone Company is my main service line and neither I nor anyone in my household receives Lifeline Support for any other telecommunications 
service.  Further, I understand that Lifeline is a federal benefit program that provides a monthly discount on either home or mobile service and 
ONLY ONE Lifeline discount is allowed per household.  Members of a household are not permitted to receive Lifeline Support from multiple 
telecommunications providers.  I understand that violation of the one‐per‐household requirement will result in de‐enrollment from the program 
and possible fines and imprisonment.  As the Certifying Subscriber claiming income eligibility, I certify that the documentation I have provided 
accurately represents: (i) my household income and the number of persons in my household; or, (ii) proof of participation in an eligible program.
I fully understand that the Lifeline Program is administered by the Universal Service Administration Company (USAC) under the guidance and 
authority of the Federal Communications Commission (FCC)and that all of the information that I have supplied pertaining to my eligibility will be 
shared with USAC and the FCC and I give my consent to do so.
I certify that I will notify Inland Telephone Company within 30 days,(i) if for any reason I should no longer participate in any of the eligible programs or qualify by 
income, and or (ii) if I move from the address provided on this form.  If my address listed above is temporary, I certify that I will verify my address to Inland 
Telephone Company every 90 days.  I understand that if I fail to respond to an attempt to verify my address within 30 days, my Lifeline support may be 
terminated.  I understand that if I fail to give notice as required, I am subject to penalties, including de‐enrollment, being barred from the program and fines and 
imprisonment.
Further, I fully understand that in order to continue to receive this support, I must annually, or more often, certify my eligibility and provide proof of eligibility.  I 
understand that my failure to timely re‐certify will result in de‐enrollment and termination of my Lifeline benefits.
I understand that Lifeline Support is not transferrable and that I may not transfer my service to any individual, including another eligible Lifeline Support 
recipient.  I further understand that if my service goes unused for 60 days, my service will be suspended subject to a 30 day period in which I may use the service 
or contact Inland Telephone Company to confirm that I want to continue receiving the service.
APPLICANT (PRINTED)
Filename: 161025 LIFELINE CERTIFICATION FORM.xlsx LIFELINE CERTIFICATION Page 2 of 3
INLAND TELEPHONE COMPANY
[phone]; [phone]
Fax: [phone]
Email: [e-mail]
103 S. 2ND Street
P.O. Box 171
Roslyn, WA 98941
1)
YES NO
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>If you checked NO, please answer question #2.
2)
A.YES NO
B.YES NO
C.YES NO
D.YES NO
E.Other YES NO
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3)
YES NO
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Please initial the certification below and sign and date this worksheet which must accompany your Lifeline application.
A.
B.
DATE
If you checked NO for each statement above, you do not need to answer the remaining questions.  Please initial line B, below, and sign and date the 
worksheet.
If you checked YES, please answer question #3.
Do you share living expenses (bills, food, etc.) and share income (either your income, the other person’s income or both incomes 
together) with at least one of the adults listed above in question #2?
If you checked NO, then your address includes more than one household.  Please initial lines A and B below, and sign and date the worksheet.
If you checked YES, then your address includes only one household.  You may not sign up for Lifeline because someone in your household already 
receives Lifeline.
The adults you live with are part of your economic unit if they contribute to and share in the income and expenses of the household.  An adult is 
any person 18 years of age or older, or an emancipated minor (a person under age 18 who is legally considered to be an adult).  Household 
expenses include food, health care expenses (such as medical bills) and the cost of renting or paying a mortgage on your place of residence (a 
house or apartment, for example) and utilities (including water, heat and electricity).   Income includes salary, public assistance benefits, social 
security payments, pensions, unemployment compensation, veteran’s benefits, inheritances, alimony, child support payments, worker’s 
com ensation benefits  gifts  and lotter  winnin s
Spouses and domestic partners are considered to be part of the same household.  Children under the age of 18 living with their parents or 
guardians are considered to be part of the same household as their parents or guardians.  If an adult has no income, or minimal income, and lives 
with someone who provides financial support to that adult, both people are considered part of the same household.
SIGNATURE OF APPLICANT
CERTIFICATION
LIFELINE HOUSEHOLD WORKSHEET
If you checked YES, you may not sign up for Lifeline because someone in your household already receives Lifeline.  Only ONE Lifeline discount is 
allowed per household.
Other than a spouse or partner, do other adults (people over the age of 18 or emancipated minors) live with you at your address?
Another adult relative (such as a sibling, aunt, 
cousin, grandparent, grandchild, etc..)
An adult roommate
An adult son or daughter
A parent
Your household is everyone who lives together at your address as one economic unit (including children and people who are not related to you).
I certify that I live at an address occupied by multiple households.
I understand that violation of the one‐per‐household requirement is against the Federal Communications Commission's rules and may 
result in me losing my Lifeline benefits, and potentially, prosecution by the United States Government.
APPLICANT (PRINTED)
You have been asked to complete this Worksheet because someone else may currently receive a Lifeline‐supported service at your address.  This 
other person may or may not be a part of your household.  Answer the questions below to determine whether there is more than one household 
residing at your address.
Does your spouse or domestic partner (that is, someone you are married to or in a relationship with) already receive a Lifeline‐
discounted phone? (check NO if you do not have a s ouse or partner
Filename: 161025 LIFELINE CERTIFICATION FORM.xlsx LIFELINE CERTIFICATION Page 3 of 3
[phone]; [phone]
Fax: [phone]
Email: [e-mail]
103 S. 2ND Street
P.O. Box 171
Roslyn, WA 98941
INLAND TELEPHONE COMPANY
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ACCEPTABLE DOCUMENTATION REQUIRED FOR LIFELINE INCOME ELIGIBILITY
When requesting Lifeline based on income eligibility (i.e., the consumer’s household income is at or below 135% of the Federal Poverty 
Guidelines), the consumer must provide documentation of income eligibility at the time of enrollment.  Any one of the following documents is 
acceptable to be used to verify income eligibility for Lifeline:
The prior year’s Federal Tax Return; or
The prior year’s State Tax Return; or
The prior year’s Tribal Tax Return; or
Three consecutive months’ worth of income statements from an employer or paycheck stubs within the current calendar year; or
Divorce Decree documenting income; or
Child Support Document documenting income; or
Social Security Statement of Benefits; or
Veterans Administration Statement of Benefits; or
An Unemployment/Worker’s Compensation Statement of Benefits; or
Federal or Tribal Notice Letter of Participation in General Assistance.
If the consumer presents documentation of income that does not cover a full year, such as current pay stubs, the consumer must present three 
consecutive months’ worth of the same types of document within the calendar year.
Filename: 160527 LIFELINE CERTIFICATION FORM.xlsx LIFELINE CERTIFICATION Page 4 of 4
LINE 3017 ‐ RUS ANNUAL REPORT AND ALL REQUIRED 
DOCUMENTATION 
(472423 ID 3017 INLAND RUS OPERATING STATEMENT.pdf