20200109Columbine Telephone Co Form 555.pdf

Annual Lifeline f,ligible Telecommunicstions Crrrier Certification Form All carriers must complete all or portions
of all sections Form must be submitted to USAC and filed with the Federal Cornmunications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
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Does the reporting company have affiliated ETCs? Yes E[ No E[
Proide a list of all ETC| that are ofrlidted wilh lhe reporting ETC, using page 4 ond additional sheets if necessary. Afrliation shall be
determined in accordance ,teith Section 3Q) ofthe Communicalions Act. Thal Section delines "afliliole" as "a pe$on thal (diectly or indirectv
owts ot controls, is ovned or contolled by, ot is under coirmon ownership or conlrolwith, dnothet person." 17 U.S.C. $ 153(2). See also 47
c.F.R. S 76.1200.
Affiliated ETC'S SAC Affiliated ETC's Name
.1 ra
-,.h v,,,.: -, m'tt; -, t C)a)- (o mai ,:. '=$i.=fr
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Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecom,n hicatior$ Carier (ETC) musl ptovide d certification form for each SAC through which it protides Likline seryice\
472295 14301 1736
State
ID2019 Columbine Telephone Co. lnc
ETC Name
HORIZON COMMUNICATIONS INC
Recertification Year
N/A
Holding Company Name
(f sane as ETC nane, list "li/A" Do rrot leare blank)
DBA, Marketing, or Other Branding Name
(lf same as Erc name, list "N1A" Do !g! leave blank)
Deadline: January 31t (Annually)
ETC$ Subject to the Non-Usage Requirements
All ETCs must complete the oppropriore check-box. ETCs that do not assess and collect a monthly lee from their Lifeline subscibeo are subjecl
to the non-usage requireme s. ETCS subject lo lhe non-usage requiredents mtst indicale the number offlbsciben de-enrolled by month in
Seclion 4. ETC9 that only assess afee but do not collecl such fees arc subject lo the non-usage requiremenls and mkst also indicate the number of
suhscrihers de-enmlletl bu nonth
Is the ETC subject to the non-usage requiremerts? Yes @ No E[
Ifyes, record the number ofsubscibers de-enrolledfor non-usage by month in Block Q below.
o
Month Subscribers De-Enrolled for Non-Usage
January 0
February 0
March 0
April 0
May 0
June 0
July 0
Aug!st 0
September 0
Octobcr 0
November 0
December 0
Total Subscribers 0
For purposes of this hling, an officer is an occupant ofa 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 tpically be president, vice president for operations, vice president for finance,
comptroller, treasurer, or a comparable position. Ifthe filer is a sole proprietorship, the owner must sign the certification.
Initial Certification Alt ETC" -u"t conpterc rhis 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 andlor program-based eligibility prior to his or her effollment in Lifeline; and/or
B) Confirm consumer eligibility by relying upon access to a state database and/or notice ofeligibility from the state
Lifeline administrator prior to enrolling a consumer in the Lifeline program.
I am an ofhcer ofthe company named above. I am authorized to make this certification for the Study Area Code listed
above.
MMInitial
P
Minimum Service Level
I certiry 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 ofthe company named above. I am authorized to make this certification for the SACs listed above.
Initial MM
Annual Recertification
Do not leave empty blocks. lfan ETC has nothing to repon in a bloclL enter o zero.
Report the number of Lifeline subscribers due for r€cfftification by month (January-December)A. Subscribers eligible for recertification by anniversary monthB. Subscribers de-enrolled prior to rccertification ottemptsC, Total number ofsubscribers ETC is responsible for recertirying (A-B)
Recertifi cation Methods
Saate of fedcrsl datrbaseD. Subscribers recenilied through ETC access to state or ttderal databasc by anniversary month
thc number ol'subscribcls verified acccss to a state or federal database,
E. Name ofthe data sourcqs) uscd to verifo consumer eligibility:
ETC Direct ContrctF. Subscribers contacted by ETC directly to reccftiry (You may also use this scction to report subscrib€f, initiated recertifications).
the numbcr ol Lifelinc subscribeni thc ETC contacted to obtain recertification of
G. Subscribers who failed to recertify through ETC dirccl outreach attempt
R the number of Lif-elire subscribeN de-effolled due to inc se to the ETC'S oulrcach attem
3
Jan teb M8r Apt N'l a1-'Jun Jul Aug sep 0ct Dec Year
Total
2 2 0 0 0 I I 0 0 0 0 1 7
0 0 0 0 0 0 0 0 0 0 0 0 0
C 0 0 0 1 0 0 0 0 1 7
May Jun sepJant'eb Ilar Apr Jul Aug Oct Nov Dec Year
Totsl
D 0 0 0 0 0 0 0 0 0 0 0
Jan Apr May Jun Jul Aug sep Oct Dec Year
Total
Feb Mar
F 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr M8y Jun Jul sep Oct Dec Year
Totsl
0 0 0 0 0 0 0 0 0 0 0
B.
lzlz Ir
I
0 0
I0 0 0
Aug
c 0 0
H. Subscribers who rcccrtified through ETC direct outrcach attempt
the number ofl-ifcline subscribe$ thal success reccrlified ETC's oulreach attc
Third PsrtyI. Subscribe6 whose cligibility was rwiewed by state administrator, third party administrator, or USAC
the nurnbc, of Lifcline subscribers contacled a statc adminisFdtor. third pany administrator, or USAC for thc se of recertification
J. Name ofthird party administrator uscd to veri! subscriber eligibility:
K. Subscribers de-cnrolled as a result ofa third party rccertification attempt
the number of subscribcrs as a result ofineligibility or () outrcach from a state administmlor, third administrator, or USAC
L. Subscribers who recertified through a state administratot third party administrator, or USAC'S recenification cffort
the number of subscribcrs that rcccrtified uesl ftom a statc administmtor. third administrator- or USAC
Certification:
Recertification Method: Drtrbase
I certify that the company listed above has procedures in place to recertify consumer eligibility by relying on a database. I
am an ofTicer ofthe company named above. I am authorized to make this certification for the SAC(s) listed above.
Initial
4
.rsn Feb \l ar Ap.Ilay Jun Jul Aug Oct Dec Yerr
Total
Sep
H,0 0 0 0 0 0 0 0 000 0 0
Jan Feb Mar Apr Ilt a1 .Iun Aug sep ()ct Nov Dec Year
Total
I 0 0 0 0 0 0 0 0 0 0 0
Jan Feb \I ar Apr May Jun Jul Aug Sep Oct Nov Dec Yesr
Total
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan MarFeb Apr Nl ay Jun Jul Aug S"p Oct Nov Dec Year
Total
l_0 0 0 0 0 0 0 0 0 0 0 0 0
Jul
0 0
Recertifi cation lllethod: ETC
I cenify that the company listed above has procedures in place to recertifu the continued eligibility of all of its Lifeline
subscribers, and that, to the best ofmy knowledge, the company obtained sigrred 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
Recertilication Method: Third Party
I certi$ that the company listed above has procedures in place to recertiff 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
dat^ year.l am an officer ofthe company named above. I am authorized to make this certification for the SAC listed
above.
Initial
Nr = (G+K)N = (D+F+t)o = M/N*r00
Total number ofsubscribers de-enrolled as
a result of recertificatlon
Totsl number ofsub$cribers ETC is
responsible for recerlifying
Percent ofsubscribers due for
recertlficstiotr who were de.cnrolled
0 0.0%
Signature Block
By signing below, I certiry that the company listed above is in compliance with all federal Lifeline certification
procedures. I am an officer ofthe company named above. I am authorized to make this certification for the Study
Area Code (SAC) listed above.
Signed,
Michelle Motzkus, Corporate Secretar Michelle Motzkus, Corporate Ser
Signaturc of Officer
[e-mail]
Printcd Name and Title ofOffrcer
Jan Ol, 2O2O
Email Addrcss ofolficer
Bonnie Jackson
Person Completing This Certification Form
Date
307-883-601 1
5
0
Contact Phone Number
Affiliated ETCs
SAC Name
512295 Silver Star Telephone Co. lnc
519001 Silver Star Telephone Co. lnc.
5'19005 Gold Star Communications LLC
47901't Gold Star Communications LLC
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