20190122Columbine Telephone Form 555.pdf

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Annual Lifeline Etigible Telecommunications Carrier Certilication Form All ca:riers must complete aU orptti6liS
of all sections Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST ,'.i .,,tit: Il+
Deadline: January 31't (Annually)
472295 143011736
Study Area Code (SAC) Service Provider ldentification Number (SPhf)
(An Eligible Telecommunications Carrier (ETC) must provide a certification form for each SAC through which it provides Lifeline semice) .
2018 lD Columbine Telephone Co. lnc
Recertification Year
N/A
State ETC Name
HORIZON COMMUNICATIONS INC
DBA, Marketing, or Other BrandingName
(f same as ETC name, list "N/A" Do ylleave bhnk)
Holding CompanyName
(If same as ETC name, list "N/A" Do not leave blank)
Does the reporting company have affiliated ETCs? Yes @ No @
Provide a list of all ETCs that are alliliated with the reporting ETC, using page 4 and additional sheets if necessary. Afiiliation shall be
determined in accordance with Section 3(2) ofthe Communications Act. That Section de/ines "afiiliate" as "a person that (directly or indirectly)
owns or controls, is owned or controlled by, or is under common ownerchip or control with, another person." 47 U.S.C. S 153(2). See also 47
c.r.R. $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
,4!,1\J lt
1
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 subscibers 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 @
Ifyes, record the number of subscribers de-enrolledfor non-usage by month in Block Q below.
P 0
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 officff is an occupant of a position listed in the article of incorporation, axticles 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 Certificatiott All ETCs rnust 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) Confrm 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.
MMInitial
2
Minimum Service Level
I certifu 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 MM
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 recedi&ing (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 verified access to a state or federal database.
E. Name of the data source(s) used to veriff consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recerti$ (You may also use this section to report subscriber initiated recertifications).
the number of Lifeline subscribers the ETC contacted to obtain recertification of
G. Subscribers who failed to recertiff 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.1 0 0 1 0 2 0 0 0 0 0 0 4
B 0 0 0 0 0 0 0 0 0 0 0 0 0
C.1 0 0 1 0 2 0 0 0 0 0 0 4
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
D.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan AP.May Jun Jul Aug DecFebMarsep0ctNov Year
Total
F 1 0 0 1 0 2 0 0 0 0 0 0 4
Jan Feb Mar APr May Jun Jul Aug Sep Oct Nov Dec Year
Total
G.0 0 0 1 0 0 0 0 0 0 0 0 1
H. Subscribers who recertifiedthrough ETC directoutreach atternpt
the number of Lifeline subscribers that recertified ETC's oukeach
Third Party
I. Subscribers whose eligibility was reviewed by state adminisfrator, third party adminisrator, or USAC
the number ofLifeline subscribers contacted a state administrator,third adminishator,or USAC for the of recertificatim.
J. Name of third party administrator used to veriff subscriber eligibility:
K. Subscribers de-enrolled as a result of a third party recertification attempt
the number of subscribers as a result of or to outreach from a state adminisfator,thtd administrator, or USAC.
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number of subscribers that recertified a from a state administrator, third or USAC
Certification:
Recertification Method: Database
I certiff that the company listed above has procedures in place to recertiff consumer eligibility by relying on a database. I
am an offlcer of the company named above. I am authorized to make this certification for the SAC(s) listed above.
Initial
4
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
H.1 0 0 0 0 2 0 0 0 0 0 0 3
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
I.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
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
Recertifi cation Method: ETC
I certiff 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 MM
Recertification Method: Third Party
I certiff that the company listed above has procedures in place to recerti$r 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 certiff that my company did not claim federal low income support for any Lifeline subscribers for the curent 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 certiff 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,
Michelle Motzkus, Secretary/Legal &M ichelle Motzkus, Secretary/Leg
Signature of Officer
mamotzkus@silvers !q14e!
Email Address of Officer
Bonnie Jackson
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 18,2019
Date
307-883-601 1
Contact Phone Number
M=(c+K)N=@+F+D O = M/N*100
Total number of subscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recertifying
Percent ofsubscribers due for
recertification who were de-enrolled
1 4 25.0%
5
Affiliated ETCs
SAC Name
512295 Silver Star Telephone Co. lnc.
519001 Silver Star Telephone Co. lnc.
51 9005 Gold Star Communications LLC
479011 Gold Star Communications LLC
6