20180131Custer Telephone Cooperative Form 555.pdf

G,v R- T- t2'o I
Annual Lifelinc Eligible Telecommunications Carrier Certification Form All carricrs must complctc all or portions
of all sections Form must be submitted to USAC and filed with the Federal Communicatir:ns Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 3I* (Annually)
Does the reporting compeny have affiliated ETCs? Yes EI No E[
Provide a list af all ETCs thdt are alliliated with the reporting ETC, using page 4 and additional sheets d necessary" Af/ilia,ion shall be
deternined in aeeordance with Section jQ) ofthe Connrunications Act. That Section deJines "affilidte" as "a person that (directly or indirectly)
o*'ns or controls, is ov,ned or contolled by', or b under common ownership or conlrol with. another pcrson." 47 U.S.C. S I53(2). See also 47
cr'.R. $ 76.t200.
Affiliated ETC's SAC Affiliated ETC's Name
(nc)
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472218 143002512
Study Area Code (SAC) Service Provider ldentification Number (SPIN)
(An Eligible Telecammunications Carrier (ETC) mast provide a certilicacionfamtfor etch SAC through which it provides Li/eline service).
2017 lD Custer Telephone Cooperative lnc.
Recertification Year
N/A
State ETC Name
Custer Telephone Cooperative, lnc.
DBA, Marketing, or Other Branding Name
(lf same as ETC name, list "N/A" Do not leave blank)
Holding Company Name
(If same rc ETC name, list "N/A" Do not leove hlank)
ETCs Subject to the Non-Usage Requirements
,1ll ETCs must c'omplcte thc appropriote _check-box. ETCs lhat do rror 4s"$ers and collecl a manthlvlbc.from their Lifeline subscribers are subject
l<t the non-u.sage requirements. ETC.s subject to thc non-usage requiremen(s must indicate the number of subscribers de-enrolled by month iiScclion 4. ETCs that onl-v* assess _afee but do not collecl suchfees are subjecl to lhe non-usoge requirements and must also indicati the number of
s u bs c r i hers de -en ro lled'b.t' mo n th.'
Is the ETC subject to the non-usage requirements? Yes EI No E[
Il' .),es, record xhe number of'subscribers de-enrolled lar non-usoge by nonth in Block Q helow.
P 0
Month Subscribers De-Enrolled for Non-Usage
January 0
February 0
Marclr 0
April 0
May 0
Jr.rne 0
July 0
August 0
Septernber 0
October 0
November 0
December 0
Total Subscribers 0
For purposcs 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 otlicer is a person whn occupies a position specified in the corporate by-larvs (or
partnership agreement), and would typically be president, vice president for operations, vice president for finance,
comptrollcr, treasurer, or a comparable position. If tlre filer is a sole proprietorship, the owner must sign the certification.
Initial Certilicatiott ttt 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
incorne 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 an#or notice of eligibility from the state
Lifeline administrator prior to eruolling a consumer in the Lifeline program.
I am an oftcer of the company named above. I am authorized to make this certitication for the Study Area Code listed
above.
dtInitial
2
Minimum Service Level
I certifo 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 fur the SACs listed above.
Initial dt
Annual Recertification
I)o not leove empty h/locks. I.f an ETC has nolhing to nrport in q bktck, anter a zero.
Reporr the number of Lifeline subscribers due lor recertification by month (January-December)
A. Subscribers eligible for recertification by anniversary nronthB. Subscribers de-enrolled prior to rccertification attemptsC. Total number olsubscribers ETC is responsible for recertifring (A-B)
Rccerti{ication Methods
State of federal databaseD. Subscribers rccertified through ETC access to state or federal databasc by anniversary month
the nunrber of verificd acces$ to a slate or lerjeral database.
E. Name of the data source(s) used to verifo consumer eligibility:
ETC Direct ContactF. Suhscribcrs contactcd by ETC directly to recertify (You may also use this section to repsrt subscriher initiated recertifications).
ol Li contacted to obtain of
G. Subscribers who failed to recefiiry through ETC direct outreach attempt
the number of Lifeline due to or to rhe El'C's outreach
3
Jan Feb Illrr Apr IlIay Jun Jul Aug Sep Oct Nov Dec Year
Total
A.0 0 0 0 0 0 0 2 2 3 5 4 16
B.0 0 0 0 0 0 0 0 0 0 0 0 0
C 0 0 0 0 0 0 0 2 2 3 5 4 16
Year
Total
Jan Feb lVIar Apr illay Jun Jul Aug sep Oct Nov Dcc
0 0 0 0 0 0 0 0 0 0D.0 0 0
Nov Dcc Ycar
Total
Jan Fcb l\Iar Apr May Jun Jul Aug sep Oct
t-0 0 0 0 0 0 0 2 2 3 5 4 16
Jan j\Iar Apr lllay Jun Jul Aug Scp 0ct Nov Dec Year
Total
Feh
0 0 0 0 0 0 2 2 1 5(i.0 0 0
Jan Fcb IVar Apr l\f ay Jun Jul Aug Sep Oct Nov Dcc Year
Total
H.0 0 0 0 0 0 0 2 2 1 3 3 11
H. Subscribers who recertified through ETC dircct outreach attempt
lhc of Lilcline ETC's
Third Party
I. Subsoibers whose etigibility was reviewed by state administrator. third parly administrator. or USAC
the number ol'Lifsline subscribers contacted a state administrator, third or USAC lbr the of recortificrtion.
J. Name of tlrird party adrninistrator used to verify subscribcr cligibility:
K. Subscribers de-enrolled as a result ofa third parly recertification attempt
the number ofsubscribers as a resul( of or to outreach from a state administrator, third administrator, or USAC.
L. Subscribcrs who recertitied through a state administrator, third party administrator, or USAC's recerlilication effort
the number ofsubscribers that recerti{ied a from a sute administrator.third administrator,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 certifrcation for the SAC(s) listed above.
Initial
4
Jan Feb l\{ar Apr May Jun Jul Aug S"p Oct Nov Dcc Year'fotal
t.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb I'Iar Apr i\Iny Jun Jul Aug scp Oct Nov Dec Year
Total
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan l'eb ll ar Apr l\,lay Jun Jul Aug Sep Oct Nov Dcc Your
1'otrl
L,0 0000 0 0 0 0 0 0 0 0
Recertifi cation lllethod: BTC
I certify that the company listed above has procedures in place to recertify the continued eligibility of all of its Lifeline
subscribers, arrd 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
certihcation for the SAC(s) listed above.
Initial dt
Recertification Method: Third Party
t 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 uamed abovs. I am authorized to make this certification for the SAC(s)
listed above.
Initial
No Subscribcrs
I certify that my company did not claim federal low income support for any Lifeline subscribers for the cunent Form 555
data year. I am an offrcer of the company named above. I am authorized to make this certification for the SAC listed
above.
Initial
Signature Block
By signing bclow, 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,
Dennis Thornock
Signatirre of Ofticer
[e-mail]
Email Address of Officer
Sherry Maestas
Person Completing This Certification Form
Dennis Thornock
Printed Name and Title of Oflicer
Jan 31,2018
Date
208-879-4008
Contact Phone Number
t\I - (C+K)N - (D+F+I)O - ilI/lirl00
Total numbcr ofsubscribcrs dc-enrollcd as
B rc$ult of rccertificalion
'Iotll number of subscribers ETC is
rcsponsiblc for rcccrtifying
Percent ofsubscribcrs duc for
rccertification who ryere de-enrollcd
5 16 31 .25%
5
Affiliated ETCs
SAC Namc
479015 Custer Telephone Broadband Services LLC
6