20180126Virgin Mobile Form 555.pdf

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
Deadline: January 31x (Annually)
Does the reporting company have affiliated ETCs? Yes E No @
Provide a list of all ETCs that are alfiliated 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 "a/filiate" as "a person thal (directly or indirectly)
owns or controls, is owned or controlled by, or is under common ownership or contol with, anolher person." 47 U.S.C. lj 153(2). See also 47
cr.R..f 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
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479015 143033426
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Caruier (ETC) must provide a certification form.for each SAC through which it provides Lifeline service).
2017 ID Virgin Mobile USA LP
Recertification Year
Assurance Wireless
State ETC Name
DBA, Marketing, or Other Branding Name
(lf same as ETC name, list "N/A" Do not leave blank)
Holding Company Name
(I/ same as ETC name, list "N/A" Do not leave blank)
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropriate check-box. ETCs that do nol assess and collect a monthlyfeefrom their Lifeline subscribers are subject
to the non-usage riquirements. ETCs subject to the non-usage requirements must indicate the rurmber ofsubscribers de-enrolled hy 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
subscrihers de-enrolled hy month.
Is the ETC subject to the non-usage requirements? Yes @l No @
Ifyes, record the number of subscribers de-enrolled for non-usage by month in Block Q below.
P o
Month Subscribers De-Enrolled for Non-Usage
January 124
February 65
March 76
April 68
Mav 82
June 73
July 73
August 71
September 4
October 1
November 5
December 1
Total Subscribers 643
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 ott Alt ETCs musr complete this section
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 progmm.
I am an officer of the company named above. I am authorized to make this certification for the Study Area Code listed
above.
JMFInitial
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
54.408.
I am an officer of the company named above. I am authorized to make this certification for the SACs listed above.
Initial JMF
Annual Recertification
Do not leave empty blocks. If an ETC has nothing to report in a block, enler 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 recertiffing (A-B)
Recertifi cation Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
the number 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 to of
G. Subscribers who failed to recertifu through ETC direct outreach attempt
the number of subscribers de-enrolled 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 0 193 223 239 251 227 196 1329
B 0 0 0 0 0 0 54 68 87 91 71 23 394
C 0 0 0 0 0 139 155 152 160 156 173 935
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
F 0 0 0 0 0 0 139 155 152 160 156 173 935
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
G.0 0 0 0 0 0 96 71 7 2 2 0 178
0
H. Subscribers who recertified through ETC direct outreach attempt
the number of Lifeline 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. 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 nurnber ofsubscribers that recertified a from a state adnrinistrator, third administrator, or USAC
Certification:
Recertification Method: Database
I certify that the company listed above has procedures in place to recerti$z 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 Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
Feb
H.0 0 0 0 0 0 112 130 112 129 137 148
Jan f,'etl Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
0I.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
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
777
0
Recertification Method: ETC
I certify that the company listed above has procedures in place to recertiff 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 JMF
Recertification Method: Third Party
I certify 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 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,
Jay M. Franklin Jay M. Franklin
Signature of Officer
Jay. M. Franklin@sprint. com
Email Address of Officer
Andy M. Lancaster
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 26,2018
Date
913-762-6107
Contact Phone Number
5
M = (c+K)N = (D+F+r)o = M/l.l*I00
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
recertifi cation who were de-enrolled
178 935 19.04o/o
Affiliated ETCs
SAC Name
5