20180126Mud Lake Telephone Form 555.pdf

MOSSADAMS
RECEIVED
2BlB JAH 26 PH lr: 5l+
T (2O9) 9ss-6100
F [phone]
3121 W. March Lane
Suite 20O
Stockton, CA 95219
:3Al-ic Pi"JnLlciTii::; CCfu{.\iISSION
January 26,2018
Diane Hanian
ldaho Public Utilities Commission
472W. Washington
Boise, lD 83720
Re:WC Docket 14-171and IPUC Case Number GNR-T-18-01
FCC Form 555 Filing
On behalf of Mud Lake Telephone Cooperative Assn. lnc. (SAC 472227), Moss Adams LLP
respectfully submits the FCC Form 555 that was recently filed with the FCC and USAC.
lf you have any questions or concerns about this Certification, please contact me.
Sincerely,
i"i::
/,,ru-
Tym Rutkorvski
Senior Manager
(s09) 777-0137
tvm. rutkowski@ mossadams.com
TR:ch
Enclosures
Annual Lifeline Etigible 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
Deadline: January 31,l. (Annually)
Does the reporting company have affiliated ETCs? Yes E[ No E[
Provide a list of all ETCs that are affliated with the reporting ETC, using page 4 and additional sheets dnecessary. Affiliation shall be
determined in accordance with Section 3(2) of the Communicatiotts Act. That Section defines "affiliate" as "a person that (directly or indirectQ)
owns or controls, is owned or controlled by, or is under common ownership or contol with, another person." 47 U.S.C. S 153(2). See also 47
c.F.R. .{ 76.t200.
Affiliated ETC's SAC Affiliated ETC's Name
472227 143002519
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier (ETC) must provide a ceftification.form.for etch SAC through which it provides Lifeline senice).
2017 ID Mud Lake Telephone Cooperative Assn. lnc.
Recertification Year
N/A
State ETC Name
DBA, Marketing, or Other Branding Name
(lf same as ETC name, list "N/A" Do not leave blank)
Holding Company Name
(If same as ETC name, list "N/A" Do not leave blank)
1
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropriate check-box. ETCs that do not assess and collect a monthlyfeefrom their Lifeline subscribers are subject
to the non4$age requirements. ETCs subject to the non-usage requirements must indicate the number ofsubscribers 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 requirernents and must also indicate the rutmber of
subscribers de-enrolled by monlh.
Is the ETC subject to the non-usage requirements? yes E No E[
Ifyes, record the number of subscribers de-enrolled for non-usage b1, month in Block Q below.
P o
Month Subscribers De-Enrolled for Non-Usage
January 0
February 0
March 0
April 0
Mav 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 Certificatiott All ETCs must complete this section
I certiff 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) Confrm 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.
JPInitial
2
Minimum Service Level
I certifu that the company listed above is in compliance with the minimum service levels set forth in the 47 CFR Section
s4.4od.
I am an officer of the company named above. I am authorized to make this certification for the SACs listed above.
Initial JP
Annual Recertification
Do not leave empt.v blocl<s. If on 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 monthB. Subscribers de-enrolled prior to recertification attempts
C. Total number of subscribers ETC is responsible for recertiffing (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
the number of subscribers 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 recertifo (You may also use this section to report subscriber initiated recertifications).
number of Lifclinc the ETC contacted to obtain recertification
G. Subscribers who failed to recertify through ETC direct outreach attempt
the subscribers de-enrolled due to or to the ETC's outreach
3
Jan Feb Mar May Jun Jul Aug sep Oct Nov Dec Year
Total
A.0 0 0 0 0 0 0 1 0 1 1 1 4
B.0 0 0 0 0 0 0 0 0 0 0 0 0
c.0 0 0 0 0 0 1 0 1 1 1 4
Apr May Jun Jul Aug sepJanFebMar Oct Nov Dec Year
Total
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
F.0 0 0 0 0 0 0 1 0 1 1 1 4
Apr Mav Jun JulJanFebMar Aug Sep Oct Nov Dec Year
Total
G.0 0 0 0 0 0 0 0 0 0 000
Apr
0
H. Subscribers who recertified through ETC direct outreach attempt
the number of Lifeline
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. Name of third party administrator used to verify subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number of subscribers as a result of or to outreach from a state administrator, 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 from a state administrator, third administrator,or USAC
Certification:
Recertification Method: Database
I certiff that the company listed above has procedures in place to recertiff 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 Mav Jun Jul Aug sep Oct Nov Dec Year
Total
H.0 0 0 0 0 0 0 1 0 1 1 1 4
Jan Feb Mar Apr Mav Jun Jul sep Oct Nov Dec Year
Total
I.0 0 0 0 0 0 0 0 0 0 000
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
K.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
L.0 0 0 0 0 0 0 0 0 0 0 0 0
Aug
Recertification Method: ETC
I certiff that the company listed above has procedures in place to recerti$ 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 officer of the company named above. I am authorized to make this
certification for the SAC(s) listed above.
Initial JP
Recertification Method: Third Party
I certiS 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
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 certiff 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,
Justin Petersen CEO
Signature of Officer
petersen.j@mudlake. net
Email Address of Officer
Person Completing This Certification Form
Justin Petersen CEO
Printed Name and Title of Officer
Jan 25,2018
Date
Contact Phone Number
5
M=(c+K)N = (D+F+I)O = M/N*lfi)
Total number of subscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recertifying
Percent of subscribers due for
recertification who were de-enrolled
0 4 0.0%
Affiliated ETCs
Name
5
SAC