20180131Boomerang Wireless Form 555.pdf

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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 @
Provide a list of all ETCs that are affliated with the reporting ETC, using page 4 and additional sheets if necessary. Affiliation shall be
determined in accordance with Section 3(2) ofthe Communications Act. That Section de/ines "af/iliate" 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. { 153(2). See also 47
c.nR..{ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
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479022 143036595
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommttnications Carrier (ETC) must provide a certificationJbrm./br each SAC through which it provides Ldbline senice).
2017 ID Boomerang Wireless LLC
Recertification Year
enTouch Wireless
State ETC Name
DBA, Marketing, or Other Branding Name
(l/'same as ETC name, lisl "N/A" Do not leave blank)
Holding Company Name
(lJ same as ETC name, list "N/A" Do not leat,e blank)
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 subscrtbers are subject
to the non-usage requirements. ETCs subject to the non4$age requirement.s must indicate the number ofsubscribers de-enrolled by nronth in
Sectbn 4. ETCs that only assess a.fee but do not collect such.fees are subject b 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 @ No @
If 1tes, record the numher of sttbscribers de-enrolled.for non-usage by month in Block Q below.
P a
Month Subscribers De-Enrolled for Non-Usage
January 0
February 0
March 0
April 0
Mav 0
June 0
July 12
August
September 4
October 1
November 0
December 0
Total Subscribers 27
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 oll All ETCs must 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 program.
I am an officer of the company named above. I am authorized to make this certification for the Study Area Code listed
above.
KALInitial
2
10
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 GL
Annual Recertification
Do not leave empty blocks. Ifan ETC has nothing to reporl 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 monthB. Subscribers de-enrolled prior to recertification attemptsC. Total number of subscribers ETC is responsible for recertifying (A-B)
Recertifi cation Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
the number of le 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 recertify (You rnay also use this section to report subscriber initiated recertifications).
the number of Lifeline subscribers the ETC contacted to obtain recertification of
G. Sltbscribers who lailed to recertify through ETC direct outreach attempt
the number ofLifeline subscribers de-enrolled due to or non to the ETC's outreach
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
A.0 0 0 0 0 0 21 25 11 1 0 3 61
B 0 0 0 0 0 0 0 0 0 0 0 0 0
C 0 0 0 0 0 0 21 25 11 1 0 3 61
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dcc Year
Total
D 0 0 0 000 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 21 25 11 I 0 3 61
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
G.0 0 0 0 0 0 2 2 3 0 0 1 B
3
H. Subscribers who recertified through ETC direct outreach attempt
the nurnber Lifeline subscribers that successfu I recertified ETC's outreach
Third Party
L Subscribers whose eligibility was reviewed by state adrninistrator, third parry administrator, or USAC
the number of Lifeline subscribers contacted a state adnlinistrator third or USAC for the of recertification.
J. Name of third party administrator used to verify subscriber etigibility:
K. Subscribers de-enrolled as a result ofa third party rece(ification attempt
the number ofsubscribers 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 adnrinistrator,third adrninistrator, or USAC
Certification:
Recertification 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
6H00000022100I
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
t.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 Jun Jul Aug sep Oct Nov Dec Year
Total
L,0 0 0 0 0 0 0 0 0 0 000
May
Recertification Method: ETC
I certify 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 KAL
Recertification Method: Third Party
I certify 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
Area Code (SAC) listed above.
Signed,
Kimberley Lehrman, President Kimberley Lehrman, President
Signafure ofOfficer
kleh rman@readywi reless. com
Ernail Address olOfficer
Summer Algharib
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 29,2018
Date
3197434641
Contact Phone Number
M = (G+K)N = (D+F+I)O: M/N*100
Total number of subscritrers 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
8 61 13.11%
5
Affiliated ETCs
SAC Name
6