20190116Project Mutual Form 555.pdf

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,-l afi]uht'lif]line 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
._ ,:;,, i; F l I1'IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 3l't (Annually)
Does the reporting company have affiliated ETCs? Yes Eil No @l
Provide a list of all ETCs that are affiliated with the reporting ETC, using page 4 and additional sheets if necessary. Affiliation shall be
determined in accordance with Section 3(2) of the Communications AcL That Section defines "affiliate" 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. S 15i(2). See also 47
cF.R. $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Caruier (ETC) must provide a certification form for each SAC through which it provides Lifeline service).
2018 lD Project Mutual Telephone Coop Assn lnc.
472231 143002521
ETC NameStateRecertification Year
N/A
Holding Company Name
(lf same as ETC name, list "N/A" Do not leave blank)
DBA, Marketing, or Other Branding Name
(lf same as ETC name, list "N/A" Do not leave blank)
t
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 subs*ibers are subject
to the non-usage requirements. ETCs subject to the non-usage requirements must indicate the number ofsubscribers de-enrolled by month in
Section 4. ETCs that only assess afee but do not collect suchfees 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 @
lfyes, record the number ofsubscribers de-enrolledfor 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 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 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 Certificatiofi Att ETCs must complere 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.
RHInitial
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 RH
Annual Recertification
Do not leave empty blocks. Ifan 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 eligible for recertification by anniversary monthB. Subscribers de-enrolled prior to recertification attemptsC. Total number of subscribers ETC is responsible for recertifuing (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 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 may also use this section to report subscriber initiated recertifications).
of Lifeline subscribers ETC contacted to obtain recertification of
G. Subscribers who failed to recertif, through ETC direct outreach attempt
the nurnber de-enrolled due to or to the ETC's outreach
3
Jan Feb Mar Apr May Jun Jul Aug Sep 0ct Nov Dec Year
Total
A.10 12 5 2 1 0 1 0 0 5 4 I 4B
B,0 0 0 0 0 0 0 0 0 0 0 0 0
C.10 12 5 2 1 0 1 0 0 5 4 8 48
Jan Mar Apr May Jun Jul Aug Sep 0ct Nov Dec Year
Total
Feb
D.00000 0 0 0 0 0 0 0 0
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
F 10 12 5 2 1 0 1 0 0 5 4 B 4B
Jan Feb Mar Apt May Jun Jul Aug Sep Oct Nov Dec Year
Total
G.6 5 3 1 1 0 0 0 0 2 2 3 23
H. Subscribers who recertified through ETC direct outreach attempt
the that recertified ETC's outreach
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third parfy administrator, or USAC
the number of Lifeline subscribers contacted a state administrator third or USAC for the
J. Name of third parry administrator used to verify subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number of subscribers as a result of or to outreach from a state
a
of recertification.
third administrator or USAC.
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number ofsubscribers that recertified from a state administrator.third administrator.or USAC
Certification
Recertification Method: Database
I certify that the company listed above has procedures in place to rece(ify 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
Apr May Jun Jul Aug SepJanFebMar Oct Nov Dec Year
Total
H.1 0 0 1472 0 0 3 2 5 25
Jan Feb Mar Ap.May Jun Jul Aug Sep Oct Nov Dec Year
Total
I.0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Ap.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 0 0 0 0
0 0 0
Recertification Method: ETC
I certify that the company listed above has procedures in place to recertify 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 RH
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,
RICK HARDER RICK HARDER
Signature of Officer
[e-mail]
Email Address of Officer
Rick Harder
Person Completing This Certification Form
Printed Name and Title of Offrcer
Jan 15,2019
Date
2084347124
Contact Phone Number
14 = (G+K)11 = (D+F+I)o = M/1\1*100
Total number ofsubscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recertifying
Percent ofsubscribers due for
recertifi cation who were de-enrolled
23 48 47 .91o/o
5
Affiliated ETCs
SAC Name
6