20200109Gold Star Communications Form 555.pdf

Annual Lifeline Eligible 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 ila (Annually)
o-b/
Does the reporting company have alf iated ETCs? Yes E[ No lt[
Provide o list ofall ETCs thqt are alliliated with the reponilg ETC, using page 4 and additional sheets ifnecessary, Afrlistion shall be
determined in accordtnce vith Sectioh 3(2) ofthe Communications AcL That Sectiotl defines "a/frliate" as "a perron that (directly or indirectl!)
otens or conlrols, is owned or contolled by, or is under common ownership or contolvlarh, anothet petson-" 47 U.S.C. S 153(2). See also 17
c.F.R. "s 76.t 200.
Affiliated ETC's SAC Affiliated ETC's Name
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479011 143032440
State ETC Name
Horizon Communications, lnc.
Recertification Year
N/A
DBd Marketing, or Other Branding Name
(lf rane as ETC nane, list "N/A" Do not leave blank)
Holding Company Name
(IJsahe as ETC hone, list "N/A" Do not leave blan*)
1
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecon,nuhications Carier (ETC) must provide o ce irtcatioh fonn lor eoch SAC through which it proides Lifeline senice).
2019 lD Gold Star Communications LLc
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropiate check+ot. ETCs that do not assess and collea a monthlyfee fron their Lileline subsciben are subject
to the non-usaEe rcquirements. ETCs subjea b the non-usage requireme s must indicate the number ofsubscibers de-enrolled by month in
Section 4. ETC| that only assess a lee but do not collect such fees are subject to the non-usage requircments and must also indicate the nrmbel of
xbscribers de-enrolled by month.
ls the ETC subject to the non-usage requiremetrts? Yes E[ wo Eil
Ifyes, record the number ofsubscribers de-enrolled.for non-usage by nonth in Blocl Q below.
P o
Month Subscribers De-Enrolled for Non-Usage
January 0
February 0
March 0
April
May 0
June
July 0
August
September 0
October
November 0
December 0
Total Subscribers
For purposes ofthis filing, an offrcer 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 typically 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 sig! the certification.
lnitial Certifica,tiolt tt crcs must complete this se.tion
I certiry 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 errollment 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 officer ofthe company named above. I am authorized to make this certification for the Study Area Code listed
above.
MMInitial
2
0
0
0
0
0
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 ofthe company named above. I am authorized to make this certification for the SACs listed above.
Initiat MM
Annual Recertification
Do not leave empty blocks. lf an ETC has nothiag to report in a blocl, enler o zero
Recertilication Methods
Statc of f€deral databaseD. Suhscribgrs recenified through ETC access to state or l'ederal databasc by anniversary month
lhe numbo'of blc subscribcrs veri6ed access to a shtc or l€deral datahase
E. Name ofthe data sourcc(s) used to veriry consumer eligibilily
the numbcr of Lifeline subscribers the EfC contacted lo oblain recerli fioation of bil
C. Subscribcts who failed to recertiry through ETC dirclt ouFcach attempt
the numh!'r of Lifblinc subscribos de-errolled due to hil to the ETC s outreach
Jsn I,'cb l\l ar Ap.May Jun Jul Aug Sep Oct Dec Year
Totsl
0 0 0 0 0 0 0 0 0
B.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
.l8n Feb Mar Apr Nl ay Jun Jul Aug sep Oct l)ec Year
Total
t)0 0 0 0 0 0 0 0 0 0 0 0 0
Jan lel,tv ar Apr M.]'Jun Jul Aug Sep Oct \ov Dec Year
Totrl
F 0 0 0 0 0 0 0 0 000 0
.{pr Mav Jun Jul Aug scp Oct Year
Total
Jan Feb Mer
G 0 0 0 0 0 0 0 0 0000
Rc?ort thc number of Lifeline subscribers due for recertification by month (January-December)A. Subscribers eligiblc for recertification by anoivgrsary monthB. SLrbscribcrs de-enrolled prior to recertification attemptsC. Total numher ofsubscribers ETC is responsible for recertifying (A-B)
0 I 0 0 0
0
ETC Direct ContrctF. Subscribers contact€d by ETC directly to recenify (You may also use this section to re?on subscriber initiated rec€rtifications).
0
Dec
0
3
H. Subsc'ribers who recertifigd through ETC diied outreach attcrnpt
the number ofLifeline subscribers that successfull rcc.nificd ETC's outreach
Third Psrty
I. Subscribers whose eligibility wa-s rcviewed by smte administrator, third party administrator, or USAC
the number of Lifeline subsaribers contacted by a flate administralor, third administmtor or USAC for the ofrecenilicalion
J. Name ofthird party adminisbator used to verifu subscribct eligibility
K. Subsc'ribers de-enrolled as a result oia third party rece(ification attempt
thc number of subscribers as a result of to outreach jiom a slatc administrator. thid party administrator. or USAC
L. Subscribcrs who recertificd through a state administrdtor, third parq' administrator or [iSAC's rccenification effort
the number of sukcriben that rcocrii lied from a state administrator, drird administrator, or USAC
Certification:
Recertilication Method i Datobase
I certifo that the company listed above has procedures in place to recertifu consumer eligibility by relying on a database. I
am an officer ofthe company named above. I am authorized to make this certification for the SAC(s) listed above.
Initial
4
Jan Feb !lrr Jun Jul Aug sep Oct Dec Year
Totrl
H 0 0 0 0 0 0 0 0 0
.ran Feb lll ar Jun Jul Aug Year
Total
Apr M.y sep Oct Dec
1 0 0 0 0 0 0 0 0 0 0 0 0 0
Jtrn Feb Mar Apr May Aug sep Dec Year
Total
K 0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr Mry Jun Jul Aug sep Oct Dec Y€ar
Total
L,0 0 0 0 0 0 0 0 0 0 0 0
Apr Mry
0 0 0 0
Jun Jul Oct
0
Recertifi cation Method : ETC
I certiry that the company listed above has procedures in place to recertifo the continued eligibility of all of its Lifeline
subscribers, and that, to the best ofmy 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
Recertilication Method: Third Party
I certit/ that the company listed above has procedures in place to recertify consumer eligibility by relying on an
administrator. I am an officer ofthe company named above. I am authorized to make this certification for the SAC(S)
listed above.
Initial
No Subscribers
I certifu 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 MM
M = (G+K)N = (D+F+l)o = M/t{*|00
Total rlumber ofsubscrlbers de-enrolled &s
s result of recertlficrtion
Totil number of subscribers ETC is
resportsible for recertifying
Percent of subscribers due for
recertiticatlon $ho tdere de-enrolled
0 0 0.0%
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 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 Se(
Signature of Oflicer
mamotzkus@silverstar. net
Email Address ofOlficer
Bonnie Jackson
Person Completing This Certification Form
Printed Name and Title ofOfficer
Jan 07 , 2O2O
Date
307-883-9411
Contact Phone Numbcr
5
Affiliated ETCs
SAC Name
472295 Columbine Telephone Co. lnc
519001 Silver Star Telephone Co. lnc
519005 Gold Star Communications LLC
512295 Silver Star Telephone Co. lnc
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