20180131I Wireless Form 555.pdf

S.A/R - T- /?-o I
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 affiliated wilh the reporting ETC, using page 4 and additional sheets if necessary. Affiliation shall be
determined in accordance with Section 3(2) ofthc Communicalions Act. That Section defines "a/filiate" as "a person that (directly or indirectly)
o'v)ns or controls, is owned or controlled by, or is under common ownership or contol with, another person." 47 U.S.C. ! 153(2). See also 47
cF.R. $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
l\ta(-r .\JZ,lTlc-r C)m,-?-rn (f
l'*
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C/)C)U,oz.
1
479020 143035427
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier (ETC) must provide a certi/icationform.fbr each SAC through which it provides Lifeline service).
2017 ID l-Wireless LLC
Recertification Year
Access Wireless
State ETC Name
DBA, Marketing, or Other Branding Name
(l/ same as ETC name, list "N/A" Do 491 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 monthly fee from their Lifeline subscribers are xbjecl
to the non-usage requirentents. ETCs subject to the non-usage requirements mu,rt indicate the number ofsuhscribers de-enrolled by month in
Sectbn 4. ETCs that only assess a.fee hut do not collect such.fees are subject to the non-usage requirement.s and must also indicate the number of
suhscribers de-enrolled by month.
Is the ETC subject to the non-usage requirements? Yes @ tlo @
Il'yes, 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 I 0
Fcbruary 0
March 0
April 1
Muy 0
June 0
July 0
August 0
September 0
October 0
November 0
December 0
Total Subscribers 1
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 Certificatiott All ETCs ,nust 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.
JWInitial
2
Minimum Service Level
I certiff 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 JW
Annual Recertification
Do not leave empt.v blocks. If an ETC has nothing to report in a block, enter a zero.
Report the number of Lifeline subscribers due for recertification by month (January-December)A. Subscribers eligibte for recertification by anniversary rnonthB. Subscribers de-enrolled prior to recertification attemptsC. Total number of subscribers ETC is responsible for recertifoing (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:
None
ETC Direct ContactF. Subscribers contacted by ETC directly to recertify (You may also use this section to repoft subscriber initiated recertifications).
the number of Lifeline subscribers the ETC contacled to obtain recertification of
G. Subscribers who failed to recertify through ETC direct outreach attempt
the number of Lifeline subscribers de-enrolled due to or to the ETC's
3
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
A.0 0 0 0 0 0 0 0 1 1 0 0 2
B 0 0 0 0 0 0 0 0 1 0 0 0 I
C 0 0 0 0 0 0 0 0 0 1 0 0 1
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
D.0 0 0 0 0 0 1 0 0 100
Jan Feb Mar Apr May Jun Jul Aug Oct Nov Dec Year
Total
F 0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar May Jun Jul Aug sep Oct Nov Dec Year
Total
G 0 0 0 0 0 0 0 0 0 0 0 0 0
0
sep
Apr
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 administrator. third adr,1linistrator 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 ofsubscribers as a result of or to outreach tiom a state administrator, third administrator. or USAC.
L. Subscribers who recertified through a state administrator, third party administrator, oTUSAC's recertification effort
tlre number ofsubscribers that recertified a from a state administrator, third administrator, or USAC
Certification:
Recertification Method: Database
I certify that the company listed above has procedures in place to recerti$r 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 JW
4
Jan Feb Mar Apr May Jun Jul Aug Scp Oct Nov Dec Year
Total
H 0 0 0 0 0 0 0 0 0 0 000
Jan Feb Mar Apr Jun Jul Aug Sep Oct Nov Dec Year
Total
I.0 0 0 000000000 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 0000
May
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
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
datayear.l 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,
John Willis COO John Willis COO
Signature of Officer
[e-mail]
EmaiI Address of Officer
Sam Bailey
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 31 ,2018
Date
51 3-550-2755
Contact Phone Number
114 = 1G+K)N = (D+F+I)O: M/N*100
Total number of subscribers dc-enrolled as
a result of recertification
Total numtrer of subscribers ETC is
responsible for recertifying
Percent of subscribers due for
recertification who were de-enrolled
0 1 0.0%
5
Affiliated ETCs
SAC Name
6