20190125Mud Lake Telephone Form 555.pdf

MOSSADAMS
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T (5O9) 747-26OO
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601 w: Riverside Avenue
Suite lSOO
Spokane, WA 99201
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January 25,2019
Diane Hanian
ldaho Public Utilities Commission
472W. Washington
Boise, lD 83720
Re WC Docket 14-171and IPUC Case Number GNR-T-19-01
FCC Form 555 Filing
On behalf of Mud Lake Telephone Cooperative Assn. lnc. (SAC 472227), Moss Adams LLP
respectfully submits the FCC Form 555 that was recently filed with the FCC and USAC.
lf you have any questions or concerns about this Certification, please contact me
Sincerely,
/,w-
Tym Rutkowski
Senior Manager
(s09) 777-0137
[e-mail]
TR:ss
Enclosures
472227 143002519
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier (ETC) must provide a certificationformfor each SAC through which it provides Lifeline senice).
2018 ID Mud Lake Telephone Cooperative Assn. lnc,
Recertification Year
N/A
State ETC Name
DBA, Marketing, or Other Branding Name
(lf same as ETC name, list "N/A" Do 4pl leave blank)
Holding CompanyName
(lf same as ETC rnme, list " N/A " Do not leave blank)
Annual Lifeline Etigibte 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* (Annually)
Does the reporting company have affiliated ETCs? Yes E No @
Provide a list of all ETCs that are afiliated with the reporting ETC, using page 4 and additional sheets if necessary. Afiliation shall be
determined in accordance with Section 3(2) of the Communications Act. That Section defines "afiliate" 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 I 53(2). See also 47
c.r.R. $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
1
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropiate 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 number of subscribers 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 En No E[
Ifyes, record the number ofsubscribers de-enrolledfor 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 offrcer 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 sigrr the certification.
Initial Certificatiort Atl ETCs must complete this section
I certifu 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 andlor 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.
JPInitial
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
s4.408.
I am an officer of the company named above. I am authorized to make this certification for the SACs listed above.
Initiat JP
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 prior to recertification attemptsC. Total number of subscribers ETC is responsible for recerti[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
E. Name of the data sourc{s) used to verifo consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertiS (You may also use this section to report subscriber initiated recertifications).
ETC to obtain recertification of
G. Subscribers who failed to recertifu 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 I 2 0 0 1 1 0 0 0 0 14
B.0 0 0 0 0 0 0 0 0 0 0 0 0
C.1 0 9 2 0 0 1 1 0 0 0 0 14
Jan Feb Mar Apr May Jun DecJulAugSepOctNov Year
Total
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 1 9 2 0 0 1 1 0 0 0 0 14
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
G.1 0 0 0 0 0 1 0 0 0 0 3
0
1
H. Subscribers who recertified through ETC direct outreach attempt
the number ofLifeline 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 thftd or USAC for the ofrecertification.
J. Name of third party administrator used to verifu subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number of subscribers as a result or to outreach from a state third 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 thtd or USAC
Certification:
Recertification Method : Database
I certify that the company listed above has procedures in place to recertify 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.0 I 1 0 0 1 0 0 0 0 0 110
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 00
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 00
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.
Initiat JP
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 certifu 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,
Justin Petersen CEO Justin Petersen CEO
Signature of Officer
[e-mail]
Email Address of Officer
Tym Rutkowski
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 24,2019
Date
509-777-0137
Contact Phone Number
14 = 1G+K)N: (D+F+I)O = M/I{*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
3 14 21.42%
5
Affiliated ETCs
SAC Name
6