20180129Columbine Telephone 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 31't (Annually)
Does the reporting company have affiliated ETCs? Yes E[ No E[
Provide a list of all ETCs that are affiliated with the reporting ETC, using page 4 and additional sheets if necessary. Afliliation shall be
determined in accordance with Section 3(2) ofthe Communications Act, That Section defines "afliliate" 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 153(2). See also 47
c.r.R. $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
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472295 1 4301 1 736
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier (ETC) must provide a certiJication form.for each SAC through which it provides Lifeline sertice).
2017 lD Columbine Telephone Co. lnc
Recertification Year
N/A
State ETC Name
HORIZON COM]UUN ICATIONS INC
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "N/A" Do not leave blunk)
Holding Company Name
(lf 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 thal do nol assess and collect a monthlyfee.from their Lifeline subscribers are subject
lo the non-usage requiremenls. 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 suchfees are subject to the non-usage requirements and must also indicate the number of
subscribers de-enrolled by month.
Is the ETC subject to the non-usage requirements? Yes EI No @
Ifyes, record the number ofsubscribers de-enrolled.for non-usage by month in Block Q below.
P 0
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 by-laws (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 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 andlor 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.
BSInitial
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 BS
Annual Recertification
Do not leave empty blocl<s. If an ETC has nothing lo 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 recertiffing (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
access to a state or federal
E. Name of the data source(s) used to verify consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertiry (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 recertiff through ETC direct outreach attempt
of Lifeline de-enrolled due to or to the ETC's outreach
the
3
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
A,0 0 0 0 0 0 1 3 0 0 0 3 7
B.0 0 0 0 0 0 0 0 0 0 0 0 0
C.0 0 0 0 0 0 1 3 0 0 0 3 7
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 0 0 0
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
F 0 0 0 0 0 1 3 0 0 0 3 7
Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
Jan Feb Mar
G.0 0 0 0 0 1 3 0 0 0 3 70
0
H. Subscribers who recertified through ETC direct outreach attempt
recertified ETC's outreach
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the nurnber of Lifeline subscribers contacted a state administrator third administrator or USAC for the of recertification.
J. Name of third party administrator used to veri$ subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the nurnber ofsubscribers as a result of OI to outreach from a state administrator,third
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number ofsubscribers that recertified from a state third administrator or USAC
thatof
or USAC.
a
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
Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
Jan Feb Mar
0 0 0 0 0 0 0 0 0 0H.0 0 0
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 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
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 BS
Recertification Method: Third Party
I ce(ify that the company listed above has procedures in place to recertify 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
Arca Code (SAC) listcd abovc.
Signed,
Barbara Sessions CFO
Signature of Officer
bsessions@si lverstar. net
Email Address of Officer
Michelle Motzkus
Person Completing This Certification Form
Barbara Sessions CFO
Printed Name and Title of Officer
Jan 23,2018
Date
307-883-6690
Contact Phone Number
M=(c+K)N = (D+F+I)O = M/N*100
Total number ofsubscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responslble for recertifying
7 7 100.0%
5
Percent of subscribers due for
recertificatlon who were de-enrolled
Affiliated BTCs
SAC Name
512295 Silver Star Telephone Co. lnc
51 9001 Silver Star Telephone Co. lnc.
51 9005 Gold Star Communications LLC
479011 Gold Star Communications LLC
6