20180119Blackfoot Telephone Form 555.pdf

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Lifeline Re-Certification - FCC Form 555
January 19, 2018
ldaho Public Utilities Commission
472W. Washington
Boise, lD 83720
Re: WC Docket No. 14-171 and IPUC Case Number GNR-T-18-01
Blackfoot Telephone Cooperative, lnc. respectfully submits the attached certifications pursuant to 47 CFR S54.416
(b) and 54.410 (d) as required by the Federal Communication Commission's Lifeline Reform Order. The filing has
been mailed in accordance with ldaho Public Utilities Commission staff guidance.
Sincerely
Michelle Owens
Regulatory Specialist
Blackfoot Telephone Cooperative, lnc
1221 N. RussellSt.
Missoula, MT 59808
cc: FCC Secretary
Montana Public Service Commission
USAC High Cost & Low lncome Division
Confederated Salish & Kootenai Tribes
482235 143002531
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier (ETC) must provide a certi/icationformlbr each SAC through which it provides Lifeline serrice).
2017 MT Blackfoot Telephone Cooperative lnc.
Recertification Year
N/A
State ETC Name
BTC HOLDINGS INC
DBA, Marketing, or Other Branding Name
(f same as ETC name, list "N/A" Do y!leave blank)
Holding Company Name
(If same as ETC name, list "N/A" Do not leave blank)
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 READ INSTRUCTIONS FIRST
Deudline: January 31't (Annually)
Does the reporting company have affiliated ETCs? Yes EI No [O
Provide a list of all ETCs that are a/filiated with the reporting ETC, using page 4 and additional sheets if necessary. Alfiliation shall be
determined in accordance with Section 3(2) ofthe Communications Act. That Section defines "affiliate" as "a person that (directly or indirectly)
owns or controls, is owned or controlled by, or is under common ownership or control with, another person." 47 U.S.C. S l5i(2). See also 47
c.r.R. $ 76.r200.
Affiliated ETC's SAC Affiliated ETC's Name
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ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropriale check-box. ETCs that do not assess and collect a monthlyfeefrom their Lifeline subscribers are subject
to the non-usage requirements. ETC.s subject to the non-usage reEdrements must indicate the rumber of subscribers de-enrolled by month in
Section 4. ETCs that only assess a.fee but do not collect such.fees are subject to the non-usage requirements and must also indicate the number of
suhscribers de-enrolled by month,
Is the ETC subject to the non-usage requirements? Yes @J No @
Il yes, record the number of sttbscriber.s 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
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 byJaws (or
partnership agreement), and would typically be president, vice president for operations, vice president for finance,
comptroller, treasurer, or a comparable position. If the filer is a sole proprietorship, the owner must sign the certification.
Initial Certificati oA All ETCs musr complete this secrion
I certify that the company listed above has certification procedures in place to:
A) Review income and program-based eligibility documentation prior to enrolling a consumer in the Lifeline program, and
that, to the best of my knowledge, the company was presented with documentation of each consumer's household
income and./or program-based eligibility prior to his or her enrollment in Lifeline; and/or
B) Confirm consumer eligibility by relying upon access to a state database and/or notice of eligibility from the state
Lifeline administrator prior to enrolling a consumer in the Lifeline program.
I am an officer of the company named above. I am authorized to make this certification for the Study Area Code listed
above.
MGInitial
2
Minimum Service Level
I certify that the company listed above is in compliance with the minimum service levels set forth in the 47 CFR Section
54.408.
I am an officer of the company named above. I am authorized to make this certification for the SACs listed above.
Initial MG
Annual Recertification
Do not leave empty blocles. If an ETC has nothing to report in a block, enter a zero.
Report the number of Lifeline subscribers due for recertification by month (January-December)
A. Subscribers eligible for recertification by anniversary month
B. Subscribers de-enrolled prior to recertification attempts
C. Total number of subscribers ETC is responsible for recerti$ing (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
verified access to a state or federal database.
E. Name of the data source(s) used to verify consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertify (You may also use this section to report subscriber initiated recertifications).
the number of Lifeline subscribers the ETC contacted to obtain recertification of
G. Subscribers who failed to recertifo through ETC direct outreach attempt
of Lifeline due to or to the ETC's outreach
3
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
A.0 0 0 0 0 0 o 11 7 12 22 21 79
B o 0 0 0 0 0 0 0 0 0 0 0 0
C 0 0 0 0 0 0 6 11 7 12 22 21 79
Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
Jan Feb Mar
D.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
0 0 0 0F000000000
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
G 0 0 0 0 0 0 0 0 0 0 0 0 0
H. Subscribers who recertified through ETC direct outreach attempt
the number ofLifeline subscribers that recertified ETC's outreach
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number of Lifeline subscribers contacted a state third or USAC for the of recertification.
J. Natne of third party administrator used to verify subscriber eligibility:
USAC
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number ofstrbscribers as a result of or to outreach from a state third administrator or USAC.
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number of subscribers that recertified a from a state administrator, third or USAC
Certification:
Recertifi cation Method: Database
I certify that the company listed above has procedures in place to recertify 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.
Initial
4
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
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 Dec Year
Total
I.0 0 000 0 6 11 7 12 22 21 79
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
K.0 0 0 0 0 0 2 3 2 3 9 12 31
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
L.0 0 0 0 0 0 4 8 5 I 13 I 48
Recertification Method: ETC
I certify that the company listed above has procedures in place to recerti$r 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. I am an offrcer of the company named above. I am authorized to make this
certification for the SAC(s) listed above.
Initial
Recertification Method: Third Party
I certi$ that the company listed above has procedures in place to recertiff 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.
Initial MG
No Subscribers
I certify that my company did not claim federal low income support for any Lifeline subscribers for the current Form 555
data year. I am an officer of the company named above. I am authorized to make this certification 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 certification for the Study
Area Code (SAC) listed above.
Signed,
Marlys Gillen Controller Marlys Gillen Controller
Signature of Officer
mg i llen@blackfoot. com
Email Address of Officer
Michelle Owens
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 17,2018
Date
406-541-5131
Contact Phone Number
5
M = (c+K)N = (D+F+I)o = M/I.{*100
Total number ofsubscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recertifying
Percent ofsubscribers due for
recertifi cation who were de-enrolled
31 79 39.24o/o
Affiliated ETCs
SAC Name
472222 Fremont Telcom Co
483308 Blackfoot Telephone Cooperative lnc
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