20190122Gold Star Communications Form 555.pdf

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Annual Lifeline Eligible Telecommunications Carrier Certification Form All ca:riers must complete alf Qf i,"64tOrysi)
of all sections Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST :,'.:. ," rlt: IlrDeadline: January 31r. (Annually)
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Does the reporting company have affiliated ETCs? Yes @ No E
Provide a list of all ETCs that are affiliated with the reporting ETC, using page 4 and additional sheets if necessary. Alfiliation shall be
determined in accordance with Section 3(2) ofthe Communications Act. That Section defines "afriliate" 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 153(2). See also 47
cr.R. $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
1
Study Area Code (SAC) Service Provider Identification Number (SP[Q
(An Eligible Telecommunications Carrier (ETC) must provide a certi/icationformfor each SAC through which it provides Lifeline service).
479011 143032440
State
ID2018 Gold Star Communications LLC
Recertification Year
N/A
ETC Name
Horizon Communications, lnc.
Holding CompanyName(f same as ETC name, list "N/4" Do not leave blank)
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "N/A" Do na leave bla*)
ETCs Subject to the Non-Usage Requirements
AU ETCs must complete the appropiate 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 EII
If yes, record the number of subscribers de-enrolled for non-usage by month in Block Q below.
P o
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 Certificatiotl Atl ETCs must 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 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 administator 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. 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 eligible for recertification by anniversary monthB. Subscribers de-enrolled priorto recertification attemptsC. Total number of subscribers ETC is responsible for recerti&ing (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 verified access to a state or federal database.
E. Name of the data source(s) used to verifr consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertiff (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 recertiry through ETC direct outreach attempt
the number of 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 0 0 0 0 0 0 0
B 0 0 0 0 0 0 0 0 0 0 0 0 0
C.0 0 0 0 0 0 0 0 0 0 0 0 0
Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
Jan Feb Mar
D.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
F 0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
Feb
G.0 0 0 0 0 0 0 0 0 0 0 0 0
H. Subscribers who recertified through ETC direct outreach attempt
the number of that recertified ETC's outreach
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, thtd party administator, or USAC
the number oflifeline subscribers contacted a state third or USAC for the of recertification.
J. Name of third party administrator used to veriff subscriber eligibilify:
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 administrator,third
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number of subscribers that recertified from a state third or USAC
or USAC.
Certification:
Recertifi cation 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 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 sep Oct Nov Dec Year
Total
Jan Feb Mar
0 0 0 0 0 0 0 0 0 0H.0 0 0
May Jun sep 0ct Nov Dec Year
Total
Jan Feb Mar Apr Jul Aug
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 JuI Aug Sep Oct Nov Dec Year
Total
L,0 0 0 0 0 0 0 0 0 0 00 0
Recertification Method: ETC
I certi$ 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 offrcer of the company named above. I am authorized to make this
certification for the SAC(s) listed above.
Initial
Recertification Method: Third Party
I certiff that the company listed above has procedures in place to recertiff consumer eligibility by relying on an
administator. 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 certi$r that my company did not claim federal low income support for any Lifeline subscribers for the current Form 555
datayear.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, Secretaryllegal &M ichelle Motzkus, Secretary/Leg
Sigrature of Officer
mamotzkus@si lverstar. net
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+rg p = 1D+F+t)O = MIN*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
recertification who were de-enrolled
0 0 0.0%
5
Affiliated ETCs
SAC Name
472295 Columbine Telephone Co. lnc
51 9001 Silver Star Telephone Co. lnc.
51 9005 Gold Star Communications LLC
512295 Silver Star Telephone Co. lnc.
5