20180117Farmers Mutual Telephone Form 555.pdf

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Annual Lil'etine Etigible Telecommunications Carrier Certification l'orm All carriers must complete all or portions
of all sections Form must be submitted to IJSAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Desdltne: January 31t (Annually)
Does the reporting company have affiliated ETCs? Yes E[ No El
Provide a list olqll ETCI thqt are afrtlioted with the reporting ETC, using page 4 and cdditlonal sheets dnecvssary, A/Jiliatlon shull be
detenntned in accordance wtth Section iQ) ofthe Communications AcL That Section defines "a//iliate" as "a person that (directly or indirectly)
owns or controb, is owned or controlled by, or i^r under common ownership or control with, anothgr person," 47 U.S.C. S 153(2). See also 47
c.f'.n. $ 76.12a0.
Affiliated ETC's SAC Affiliated ETC's Name
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472221 143002514
Study Area Code (SAC) Service Provider ldentification Number (SPIN)
(An Eligible Telecommunications Carrler @TC) must proide a certificatlon{onn for aach SAC lhrough which it provides Llfeline servlce).
2017 lD Farmers MutualTelephone Company
Recertification Year
NiA
State ETC Name
DBA, Marketing, or Other Branding Name
(lfsame at ETC ttame, llst "N/A" Do not leave blank)
Holding CompanyName
(If sane os ETC name, list "N/A" Da not leave blank)
ETCs Subject to the Non-Usage Rcquirements
All ETC.r musl complele the appropriale check-box. ETCs that do not as.tess and collect a monthly/eelrom their Li.feline suhscribers are subiectto lhe non-*ragc rdquireyenis. EtCs sybicgt to the non-usage requirenrents must indicate the nuiiber"ofsuhscribei.s dc-enrolled by month iriSection.4. ETCs that-only assess a fee but do not collect suchlees are subject to the non-usage requiretienls and must also indicah the number of
suhscrihers de-enrolled by month.
Is the ETC subject to the non-usrge requirements? Yes EJ No EI
If yes, record the number olsttbscribers de-enrolledlor non-usage hy nonth it Block Q below.
P o
Month Subscribers De-Enrollod for Non-Usase
January 0
February 0
March 0
April 0
May 0
June 0
July 0
August 0
September 0
October 0
Novcmber 0
December 0
Total Subscribers 0
For purposes of this frling, 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 pcrson who occupies a position specified in the corporate by-laws (or
partnership agreement), and would typically be president, vice president for operatiors, vice president for finance,
comptroller, treasurer, or a comparable position. If the filer is a sole proprietorship, the owner must sign the certification.
Initial CeftifiCatiOtt Atl ETC: mutt coaplete this secrton
I certify that thc company listed above has certification procedures in place to:
A) Review income and program-based eligibility documentation prior to enrolling a consulner in the Lifeline prograrn" and
that, to the best of my knowledge, the company was presented with documentation of each consumer's household
income anrVor 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 fi'om the stane
Lifeline administrator prior to enrolling a consumer in the Lifeline progranl
I am an officer of the company named above, I am authorized to make this certification for the Study Area Code listed
above,
DEGInittal
2
Minimum Service Level
!certify that thc company listed above is in compliance with the minimum service levels set forth in the 4? CFR Section54.408:
I am an officer of the company naued above. I am authorized to make this certification for the SACs listed above.
Inltlal DEG
Annual Recertificatlon
Do not leave empty bloclts. I{ an ETC has nothlng to report ln a bloclc, enter a zero.
Report the uurrber of Lifolins subscribers due for reccrlification by month (January.Deoember)A. Subscriben cligible for recertification by annivcrsary monthB. Subscriben de-enrolled prior to reccrtification attcmptsC. Total number ofsubscriben ETC is rasponsible forrecertifying (A-B)
Recertifi cation Methods
State of federal databaseD. Subscribers recertificd through ETC access to statc or federal dalabase by anniversary month
the nurnber subscribers verified acccts to a state
E, Nanre ofthe data source(s) used to verif, consumer eligibility:
ETC Dircct ContactF. Subscribcrs contacted by ETC directly to recerti$ (You may also use this scction to report subscriber initiated recertifications).
the thc ETC contactql to obtain
O. Subscribers who iailed to recertifu through ETC dircct outreach attempt
dc-enrolled due to to the ETC's outrcochor
3
Jan Feb Mar Apr May Jun Jul Aug s"p Oct J,lov Dec Year
Total
A.0 0 0 0 0 0 2 7 0 1 1 3 14
B.0 0 0 0 0 0 0 I 0 1 0 0 2
c.0 0 0 0 0 0 2 o 0 0 1 3 12
Jan !'eb lVlar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
D,0000 0 0 0 0 0 0 0 0 0
Nov Dec Year
Total
Jan Feb Mar Apr May Jun Jnl Aug sep Oct
F.0 0 0 0 0 0 2 6 0 0 1 3
Jan felr Mar Apr May Jun Jul Aug sep ()ct Nov Dec Yeqr
Total
o,0 0 0 0 0 0 2 4 o 0 1 1 I
12
I
H. Subscriben who recertified through ETC direct outreach attempt
'Ihird Party
I. Subscribers whose eligibility was reviewed by $tale edministrator, third party administrator, or USAC
the number of Lifelinc subscribers cootacted a slats third
thatthe
I. Name of third party administraior used to verift subscriber eligibilityl
K. Subscribers de-enrolled as a result ofa third party recertification attempl
the number
or USAC for the of recertificarion.
tlrird or USAC.asa or to outrcach fronr a state
L. Sub*cribers who recertified tbrough a state administrator, third party administrator, or USAC's recenification effort
the number of strbscribers that from a state administrator,third or USACa
Certificatlou:
Recertificatlon Method: Database
I certi$ that the company listed ahove has procedures in place to recerti& consumer eligibility by relying on a database. I
arx an officer of the company nruned above, I am authorized to make this certification for the SAC(s) listed above.
Initial
4
Jan Feb M:rr Apt May Jun Jul Aug scp Oct Nov Dec Year
Total
H.0 0 0 o 0 0 0 2 0 0 0 2 4
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
I.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr Iltay Jun Jul Aug sep Oct Nov Dec Year
Total
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feh Mar Apr Flay Jun Jul Aug sep Oct Nov Dec Year
Total
L.0 0 0 0 0 0 0 0 0 0 0 0 0Ii
Recertification Method: ETC
I certi$ that the company listed above has procodures in place to recertif 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 atlesting
to their continuing eligibility for Lifeline. I am an offrcer of the company named above, I am authorized to make this
certilication for the SAC(s) Iisted above.
1n11i21 DEG
RecertiJlcatlon Method: Thtrd Party
I certifu that the company listed above has procedures in place to recerti$ consumer eligibility by relying on an
administrator, I am an officer of the company named above. I am authorized to make this certification for the SAC(s)
listed above.
No Subscribers
I certif that my compary did not clainr federal low income support for any Lifeline subscribers for the cunent Form 555
data year. I am an offrcer of the company named above. I am authorizcd to makc this csrtification for the SAC listed
above,
Initial
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 certilication for the Study
Area Code (SAC) listed above.
Signed,
Daniel Greig, General Manager Daniel Greig, General Manager
Signature of Officer
[e-mail]
Email Address of Officer
Krista Byrd
Person Completing This Certification Form
Printed Name and I'itle of Officer
Jan 10,2018
Date
248-452-2040
Contact Phone Number
5
p1 - (g+K)!l - (D+F+I)o - M.rN*Ifi)
Total number of subscrlbers de-enrolled ae
a result of recertlflcatlon
Total number of subscrlbers ETC ls
resporrible for recertlfylng
Percent ofsubscrlbers due for
recertlflcltion rvho were de-enrolled
8 12 66.66%
Initial
Afliliated ETCs
SAC Name
6