20180131Custer Telephone Broadband Form 555.pdf

Annual Lifeline Eligible Telecommunications Carrier Certification Form All carriers must complete all or portions
eif all sections Form must be submitled to USAC and filed with the Federal Communications Commission
IMPORTA]YT: PLEASE READ TNSTRUCTIONS FIRST
Deadline: Janaary 3l* (Annually)
Does thc reporting company havc affiliated ETCs? Yes EI No @
Provide a list of all ETCs that are a/filiated v;ith the reporting ETC, using page 4 and additional sheets if necessary. AJfiliation shall be
detennined in accorclance with Section 3(2) ofthe Connrunications Act. That Section defines "ofJiliate" at "a person that (directly or indirectly)
ottns or controls, is ov'ned or conuolled by, or is under common o*nership or control with, another person." 47 U.S.C. S I 53(2). See also 47
cF.R. $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
U'C].
c)Z
f\tee
qo
It'z,mC^> C)rn-re-,mf,s
$.
*-lr-
--{cl
{lra-
anr
1
47901 I 1 43031 048
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier (ETC) must provide o certilicationformfor each SAC through which it provides Lifeline semice).
2417 lD Custer Telephone Broadband Services LLC
Recertification Year
NIA
State ETC Name
Custer Telephone Cooperative, lnc.
DBA, Marketing, or Other Branding Name
(If sonre as ETC name, list "N/A" Do not leave blonk)
Holding Company Narne
(lf sane ns ETC nane, list *ll/A" Do not leave hlonk)
?>rvB*T -tx-ol
ETCs Subject to the Non-Usage Requirements
All ETCs must complcte lhc appropriate chct'k-bo.t. ETCs lhat do trol assess ond collcc't u monthlyjbcfron their Lilclinc subscribcrs arc subjectlo the non-usagc rcquircmcnls. ETCs subjcct to tlrc non-usage require,nents rnusl indicate the numbcr ofsubscribers de-enrolled by month in
Section 4. ETCs thnt orl;'assess ufee ba( da not collect suc'h/ees ure subject to the nan-usage requirenents and trust alsa indicate the nunber of
subscrihers de-enrolled hv nronth.
Is the ETC subject to the non-usage requirements? Yes M No E[
l'ves. record the uumber ofsuhscribers de-enrolledfor non-usage by nronth in Block Q belox'.
P a
Month Subscribers De-Enrolled for Non-Usage
January 0
February 0
March 0
April 0
May 0
June 0
July 0
August 0
Se ptember 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 thc 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 comparablc position. If the filer is a sole proprietorship, the owner must sign the certification.
Initial Certificatiort Atl ETCs must complete rhis secriott
I certify that the company listed above has certification procedures in place to:
A) Revierv income and program-based eligibility documentation prior to enrolling a consumor in the Lifeline program, and
that, to the best of my knowledge, the company was presented with documentation of each consumer's household
incon:e andlor program-based eligibility prior to his or her enrollment in Lifelinel andlor
B) Confirm consumer eligibility by relying upon access to a state database and/or notice of eligibility from the state
Lifeline adnrinistrator prior to enrolling a consumer in the Lifeline program.
I anr an officer of the company named above. I am authorized to make this certifrcation for the Study Area Code listed
above.
drlnitial
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 ofhcer of the company named above. I am authorized to make this certification for the SACs listed above.
Initial dt
Annual Recertification
I)o not leave enrytty blocks. l-fan ETC has nolhing to rcporl in a hloch enter a zero.
Report the number of Lit'eline subscribers due for recertiflcation by month (January-Deccnrbcr)A. Subscribers eligihle for rccerlification by anniversary monthB. Suhscribers de-cnrolled prior to recertiftcstion atlempts
C. Total numbcr of subscribers ETC is responsible fur recertifuing (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by annivercary month
the number of subscribers vgrilied lo a stale or fueral
8,. Namc of thc data source(s) used to verily consumer eligibility:
ETC Direct Contactf. Subscribers contacted by ETC directly tei recertify (You may also use this section to report subscriber initiated receflifications).
the number ofLifeline 1o obtain recenification of
(;. Subscribers who failed to recertiry through ETC direct outreach attempt
the nunrber of Lifelinc subscribers or lo the ETC's outreach
Jan Fch lllar Apr illay Jun Jul r\ug scp Oct Nov Ilrc Year
Totrl
0 0 0 0 0 0 1 0 0 0 0 1 2
B.0 0 0 0 0 0 0 0 0 0 0 0 0
C 0 0 0 0 0 0 1 0 0 0 0 1 2
Jan Fcb l\Iar Apr llry Jun Jul Aug sep Oct Nov Der Yenr
Total
0 0 0 0 0 0 0 0 0D.0 0 0 0
Jan Feb NIar Apr M"y Jun Jul Aug sep Ocf Nov Dec Ycar
Total
0 0 0 0 I 0 0 0 0 1 2F00
F'eb l\lar Apr ilay Jun .lul Aug Sep Oct Nov Dec Year
Total
G.0 0 0 0 0 0 0 0 0 0 0 0 0
3
.f an
H. Subscribers who recertified through ETC direct outreach attempt
thc number of Lifeline subscnbers that successfu recertificd ETC's outreach
Third PartyL Subscribers whose eligibility was reviewcd by slate administrator, third party administrator, or USAC
the number of Lifeline subscnbers contacled a state administrator. third atlministrator, or USAC for the ofrecertification.
J. Nunrc of third party administrrtor u$ed to verify subscriber cligibility:
K. Subscribers dc-enrolled as a result ofa third party recertification attempt
the number ofsubscribers as a result of or to outreach from a state administrator, third adminislrat0r or USAC.
L. Sutrscribers rvho recertitled through a state administrator, third party administrator, or USAC's reccrtilication c{Iort
the number of subscribers that recerti{-ted from a stale administrator,third adminrstrator,or USAC
Ce rtification:
Recertifi cation Method: Datatrase
I certify that the company listed above has procedures in place to recertify consumer eligibility by relying on a database. I
am an of'ficer of the conrpany named above. I am authorized to make this certification for the SAC(s) listed above.
Initial
4
Jau Fctr lVlar Apr I\Iay Jun Jul Aug Sep Oct Nov Dec Year
Total
H 0 0 0 1 0 0 0 0 1 2000
Jun Jul Scp Oct Nov I)ecJanFeblll ar Apr May Aug Year
'l'otal
0 0 0 0 0 0 0 0 0 0t.0 0 0
Jan Frb l\{ ar Apr [Iay Jun Jul Aug Sep Oct Nov Dec Year
Total
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Year
'I'otalil{ay Jun Jul Aug Scp 0ct Nov DecJrnFcb)lar Apr
0 0 0 0000000L000
Recertification Method: ETC
I certify that the company listed above has procedures in place to recertily the continued eligibility of all of its Lifeline
subscribers, and that. to the bcst ofmy knorvledge, the company obtained signed certifications from all subscribcrs attesting
to thcir continuing eligibility for Lifelinc. I am an offrcer of the company named above. I am autl'rorized to make this
certification for the SAC(s) listcd above.
Initial dt
Recertification lltethod: Third Party
I ccrtify that the company listed abovc has procedures in placc to rccertify consumer eligibitity 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.
No Subscribcrs
I certify that nry company did not clairn 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 BIock
By signing below, I ccrtify that thc con'rpany listetl above is in conrptiance with all fcderal Lifeline certification
procedures. I am an ofticer of the company named abnve. I am autlrorized to make this certification for the Study
Arca Code (SAC) listed above.
Signed,
Dennis Thornock Dennis Thornock
Signatr.rrc of 0fficer
[e-mail]
Email Address of Officer
Sherry Maestas
Person Completing This Cenification Form
Printed Name and Title of Officer
Jan 31 2018
Date
208-879-4008
Contacl Phone Number
5
M - (c+K)v = @+F+I)O = lllAirl00
Total number of subscribcrs dc-enrollcd as
a result of recertification
Total number of subscribcrs ETC is
responsible for recertifylng
Pcrccnt of subscribers due for
recertification who rvere de-enrolled
0 2 0.0%
Initial _
Affiliated ETCs
SAC Name
6