20180201Inland Cellular 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 @ No @
Provide a list of all ETCs that are alfiliated with the reporting ETC, using page 4 and additional sheets if necessary. Afiiliation shall be
determined in accordance with Section 3(2) of the Communications Act. That Section defines "ffiliate" cts "o person that (directly or indirectly)
owns or controls, is owned or controlled by, or is under common ownership or contol with, another person." 47 U.S.C. li 153(2). See also 47
c.F.n..{ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
i: tu-*.i c3
CD
::rr- r.ri ,A)',T,::'- tto fil!i.; I !(i-^ lll
^ l'
*q + m:br F
IC).^,z.
1
479007 143037458
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier (ETC) must provide a certification form for each SAC through which it provides Lifeline service)
2017 ID lnland Cellular LLC
Recertification Year
N/A
State ETC Name
lnland Cellular Telephone Company
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "N/A" Do not leave blank)
Holding Company Name
(If 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 that do not assess and collect a monthlyfeefrom their Lifeline subscribers are subject
to the non-usage requirements. ETCs subject to the non-usage requirements must indicate the rumber ofsubscribers de-enrolled by month in
Section 4. ETCs that only assess afee but do not collect such.fees 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 @ No @
If yes, record the ntrmber of subscribers 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
May 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 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 Certificatiort All ETCs tnust 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 emolling 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.
NWInitial
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 NW
Annual Recertification
Do nol leave empty blocl<s. If an ETC has nothing to report in a block, enter d 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 recertifoing (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
the number of subscribers
E. Name of the data source(s) used to verify consumer eligibility:
State of ldaho Department of Health and Welfare
ETC Direct ContactF. Subscribers contacted by ETC directly to recertifu (You rnay also use this section to report subscriber initiated recertihcations).
the number of Lifeline subscribers the ETC contacted to obtain recertification of
G. Subscribers who failed to recerti$ through ETC direct outreach attempt
the number of Lifeline subscribers de-enrolled due to or to the ETC's outreach
3
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
A.0 0 0 0 0 0 18 12 28 17 25 17 117
B 0 0 0 0 0 5 2 4 1 1 3 16
C 0 0 0 0 0 13 10 24 16 24 14 1 01
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
D.0 0 0 0 0 0 3 2 15 6 0 34
Jan Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
Feb
F 0 0 0 0 0 0 10 B o 10 16 14
Jan Feb Mar Apr Mav Jun Jul Aug Sep Oct Nov Dec Year
Total
G.0 0 0 0 0 0 o 2 3 6 4 6 30
0
0
8
67
H. Subscribers who recertified through ETC direct outreach attempt
of Lifeline subscribers ETC's outreach
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number of Lifeline subscribers contrcted a state administrator, third administrator,or USAC for the
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 or to outreach from a state administrator, third administrator, or USAC.
of recertification.
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 or USACa
Certification
Recertification Method: Database
I certify that the company listed above has procedures in place to recertiff 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.
Initiat NW
4
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
H.0 0 0 0 0 0 4 8 21 10 20 8 71
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
0I,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
Dec Year
Total
Jan Mar Apr May Jun Jul Aug Sep Oct NovFeb
0 0 0 0 0L.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 authorizedto make this
certification for the SAC(s) listed above.
Initid NW
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,
Nathan R. Weis, President, Inland Cel Nathan R. Weis, President, lnlan
Signarure of Officer
[e-mail]
Email Address of Officer
Mike Bly
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 30, 2018
Date
208-798-0245 x1222
Contact Phone Number
114 = (G+K)N = (D+F+r)O = M/l{*100
Total number of subscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recertifying
Percent of subscribers due for
recertifi cation who were de-enrolled
30 1 0 1 29.7o/o
5
Affiliated ETCs
SAC Name
529003 lnland Cellular LLC
529004 lnland Cellular LLC
6