20180118Rural Telephone Form 555.pdf

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G,vr- T- t?-o I
Annual Llfeline Eligible Telecommunlcations Can{er Certlfication 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 READ INSTRUCTIONS FIRST
Deadline: lanuary 3h (Annually)
idaho Public Utilities Commission
Office of the SecretarvRECEIVED
JAN I I 20tg
Boise, ldaho
Does the repordng company have aflillated ETCs? Yes E] No @
Provtde a ltst of all EICs that are afilioted with the repofiing ETC, using page 4 and additional sheets d necessary. Afiliation shall be
determined in accorddnce wlth Sectlon iQ) of the Communications Acl. That Section defines "afiliate" as "a person that (directly or indirectly)
oh,rrs ol conttols, ls owned or con*olled by, or is wtder common ownershlp or control wlth, another person," 47 U.S,C, S I 53(2). See also 47
c.F.x. $ 76.1200.
AffiliatedETC's SAC AJfiliated ETC's Name
5s2233 RUBAI TELEPHONE COMPANY
7
472233 143002523
Study Area Code (SAC) Service Provider Identification Number (SPbI)
(An Ellglble Telecommunlcations Canter (ETC) mwt provide a certtficalionlormfor each SAC lhrough which tt prwides Lifeline service).
2017 ID Rural Telephone Company
Recertification Year
N/A
State ETCName
RURAL TELEPHONE COMPANY
DBA, Marketing, or Other Branding Name
(If same as ETC name, llst "N/A" Do not leow blank)
Holding CompanyName
ffsame as ETC namq list "N/A" Do not leave blank)
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ETCs Subject to the Non-Usage Requirements
AU ETG must complete the appropfiate,check-bo_x. E?Cs thot do nol assess aud collect o monthlyfeefrom thelr Llfellne subscribers are subject
to the non-usoge requirements, ETCs subjecl to lhe non-usage requirernents must indicate the number ofsubscribers de-enrolled by uonlh in
Section 4. ETCs that only assess afee bul do not collect suchtees are subJecl lo the non-usage requireuents and nwst also indicate the number ol
subscribers de-enrolled by monlh.
Is the ETC subject to the non-usage requlrements? Yes EI No EI
Ifyes, recod the number ofsubscibers de-enrolledfor non-usage by month ln Block Q below,
P 0
Month Subscribers De-Euolled for Non-Usage
January 0
February 0
March 0
April 0
May 0
Juae 0
July 0
August 0
September 0
October 0
November 0
December 0
Total Subscribers 0
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,
comptoller, beasurer, or a comparable position. If the filer is a sole proprietorship, the owrer must sign the certification.
Initial Certi{icatioft ttl ETC.s nust complete tlls sectton
I certi$ that the company listed above has certification procedures in place to:
A) Review income and program-based eligibility documentation prior to enrolling a consurner in the Lifeline program, and
that, to the best of my knowledgq the company was presented with documentation of each consumer's household
income and/or program-based eligibility prior to his or her emollment in Lifeline; and/or
B) Confirm consumer eligibility by relying upon access to a stato 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
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Minimum Service Level
I certi& that the company listed above is in compliance with the minimum service levels set forth in the 47 CFR Section
54.40{.
I am an officer of the company named above. I am authorized to make this certification for the SACs listed above.
Inltlal
Annual Recertilication
Do not leave eupty blocks. Ifan ETC has nolhlng lo report ln a bloclc, enter a zero.
Report the nurnber of Lifeline subsoribers due for recertification by month (January-December)A. Subscriberr eligible for recertification by anniversary monthB. Subscribers de-enrolled prior 1o recertificatior attemptsC. Total number of subscribers ETC ie responsible for rscefiiryiDC (A-B)
Recertificatlon Methods
State of federal databaseD. Subscribers recertitred through ETC access to state or federal database by anniversary month
lho number of subscribers verified access to a state or federal dahbasc.
E. Name of the data source(s) used to veri$ consumer eligibility:
ETC Direct ContactF. Subscribcn coutacted by ETC directly to recerti$ (You may also use this section to report zubscriber initiated recertifications).
contacted obtein recertifi mtion of
G. Subscribers who foiled to recertiff througL ETC direct ouheach attempt
ths uumber oflifelino subscribcrs de-cnrollcd due to or to tho ETC's outtcach
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Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
A.0 0 0 0 0 0 1 0 0 0 0 0 1
B 0 0 0 0 0 0 0 0 0 0 0 0 0
C.0 0 0 0 0 0 1 0 0 0 0 0 1
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
D,0 0 0 0 0 0 0 0 0 0 000
Mar APr May Jun Jut Aug scp Oct Nov I)ec Year
Total
Jan Feb
F.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Mnr Apr May Jun JUI Aug sep Oct Nov Dec Year
Total
Feb
G.0 0 0 0 0 0 0 0 0 0 0 00
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II
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II
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II
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H. Subsoribers who recertified through ETC direct ouheach attempt
ofLifeline
Third PartyL Subsctibers whose eligibility was reviewed by state administato5 third party adminishator, or USAC
tho number oflifeliae subscribers contacted a state rhid or for tho ofrecertification,
J. Namo of third party administator used lo veriff subscriber eligibility:
SOLlX
K Subscribers de-enrolled as a result ofa third party recertifioation sttempt
the number ofsubscriben as a result of or to outreac.h from a statc tbird
L. Subsoribers wLo recertified througb a state administrator, third party administrator, or USAC's recertification effort
ths number ofaubscn"bers that rccertified fmm a state
or USAC.
or
Certllication:
Recefiiffcation Method: I)atabase
I certiff that the cornpany listed above has procedures in plaoe to recertifr consumer eligibility by relying on a database. I
am an officer of the company named above. I am authorized to make this certification for the SAC(s) listed above.
Inltial
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Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
TotaI
H,0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar APr May Jun Jul Aug sep Oct Nov Dce Year
TotaI
I.0 0 0 0 0 0 1 0 0 0 0 0 1
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
TotaI
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan tr'eb Mar Apr May Jun JUI Aug seP Oct Nov Dec Year
Total
L.0 0 0 0 0 0 1 0 0 0 0 0 1
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Recertilicatlon Method: ETC
I certi$ that the company listed abovs has procedures in place to recertifr the continued eligibility of all of its Lifeline
subscribers, and that, to the best of my knowledge, the company obtained siped certifications from all subscribers attesting
to their continuing eligibility for Lifeline. I am an officer of the company named above. I am authorizedto make this
certification for the SAC(s) listed above.
Recertification Method: Thlrd Party
I certiS that the company listed above has procedures in place to recerti$ consumer eligibility by relying on an
adminisffator. I am an officer of the company named above. I am authorized to make this certification for the SAC(s)
listed above.
a
Initial
No Subscribers
I certifr that my company did not claim federal low income support for any Lifeline subscribers for the ourent Form 555
data year. I am an officer of tho company named above. I am authorized to make this certification for the SAC listed
above.
Inltial
Slgnature Block
By signing bolow, I oertifr that the company listed above is in conrpliance with all federal Lifeline certification
procedures. I am an officer of the companynamed above. I am authorized to make this certification for the Study
Area Code above.
Signed,
Mlke Martell, Vlee Pr'esldentffiil-
January 18, 2018
'(
of
Bmail Address of Officer
Theresa Wilson
Person Completing This Certification Form
Date
208-366-3614
Contact Phone Number
M=(C+K)N =(D+F*D O=WN*100
Total number of eubscrlbers de-enrolled as
a regult of recerdflcaflon
Total number of subscr{bers ETC ls
rupordble fm raclrtlfying
Percent ofsubrcrlberc due for
recertlftcadon who were de.enrolled
0 1 A.}o/a
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Initial
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Affiliated ETCs
SAC Name
552233 Rural Telephone Company
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