20190130I-Wireless Form 555.pdf

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Annual Lifeline Eligible Telecommunications Carrier Certification Form All carriers must complete all or portions i
of all sections Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST , .I'. : I
Deadline: January 31,l' (Annually)
Does the reporting company have affiliated ETCs? Yes @l No @
Provide a list of all ETCs that are ffiliated 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 Act. That Section dertnes "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. { I 53(2). See also 47
cr.R. $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
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 service).
479020 143035427
ETC NameState
ID2018 l-Wireless LLC
Recertification Year
Access Wireless
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 nome, list "N/A" Do not leave blank)
1
0h
ETCs Subject to the Non-Usage Requirements
All ETCs musl complete the appropriate check-box. ETCs that do nol assess and collect a monthly fee from their Lifeline subscribers are subject
to lhe 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 a fee 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 E[ No @
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
Mav 0
June 0
July 0
August 0
September 0
October 0
November 0
December 1
Total Subscribers 1
Initial Certificati ott Alt ETCs must 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; andlor
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.
JWInitial
2
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.
Jan Feb Mar Ap.May Jun Jul Aug sep Oct Nov Dec Year
Total
A.0 1 0 0 0 0 0 0 0 1 0 0 2
B.0 0 0 0 0 0 0 0 0 0 0 0 0
C.0 1 0 0 0 0 0 0 0 1 0 0 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 JW
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 month
B. Subscribers de-enrolled prior to recertification attemptsC. Total number of subscribers ETC is responsible for recertiSing (A-B)
Recertifi cation Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
the of access to a state or
E. Name of the data source(s) used to verify consumer eligibility
ldaho PDAP
ETC Direct ContactF. Subscribers contacted by ETC directly to recertify (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 recertif) 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
D 0 1 0 0 0 0 0 0 1 0 2
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 Feb Mar Ap.May Jun Jul Aug Sep Oct Nov Dec Year
Total
0c.0 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 Lil'eline 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 third or USAC for the of recertification.
J. Name of third party administrator used to verify 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 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 from a state administrator, third administrator.or USACa
Certification:
Recertification Method: Database
I certif, that the company listed above has procedures in place to recertify 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 JW
4
Jan Feb Mar Ap.May Jun Jul Aug sep Oct Nov Dec Year
Total
H.0 0 0 0 0 0 0 0 0 0 0 00
Ap.May Jun Jul Aug Sep Oct Nov Dec Year
Total
Jan Feb Mar
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 Ap.May Jun Jul Aug Sep Oct Nov Dec Year
Total
L,0 0 0 0 0 0 0 0 0 0000
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
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,
John Willis, COO John Willis, COO
Signature of Oflicer
John.wi [e-mail]
Email Address of Officer
Sam Bailey
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 30, 2019
Date
513-550-2755
Contact Phone Number
NI: (G+K)N = (D+F+I)O = M/N*100
Total number ofsubscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recertiffing
Percent ofsubscribers due for
recertification who were de-enrolled
0 2 0.0%
5
Affiliated ETCs
SAC Name
6