20200110Albion Telephone Form 555.pdf

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Communications A.ECEiVED
p208-673-5335 t l208-673-6200 / [e-mail] t a225W.NorthSt-tlblotrtil lDF3Bi*rll'10
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G.,un r-Jo c'1
January 06, 2020
lda ho Public Utilities Commission
PO Box 83720
Boise, lD 83720-0074
I am filing a copy of my FCC Form 555 which I have also filed with the FCC and USAC. tf you have any
questions or need additional information, please let me know.
Sincerely,
Ky radshaw
Assistant General Manager
To Whom lt May Concern:
Annual Lifeline Eligible Telecommunications Carrier Certification Form All carriers must complete all or ponions
olall scctions Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31r (Annually)
Does the rcporting company have affiliated ETCs? Yes @ No @
Provide a list o/ all IiTCs that are alliliated with thc rcporling ETC, nsingpage 4 and additio al sheets if nacessory. A/liliation shall be
owns or Ltntrols it owted or conb olled lt),, or is under comnon owne$hip or control with, amther p?rson. " 47 U.S.C. ! I 5 3(2). See also 47
(..F.R. I 76.1 200.
472213 143002510
Study Area Code (SAC) Scrvicc Providcr Idcntitlcation Number (SPIN)
(An Eligible Telecoumunicalions Caffier (ET( ) must ltrovide a certilication lbrm for each SAC through nhich it ptot'ides Li/bline seLvice).
2019 ID Albion Telephone Company lnc.
Rccertification Year
N/A
State ETC Name
DBA, Marketing, or Other Branding Name
(lfsdnlc as ETC name, lilt "N/A Do not leave blank)
Holding Company Namc
(lf sane as ETC non<', list 'N/A ' Do not leave hlonk)
Alfiliated ETC's SAC Afiiliatcd ETC's Namc
1
ETCs Subject to the Non-Usage Requirements
All ETCs nust conpletc the appropriate check-box. ETCs that do not assess and collect a nonthly fee fron theb Lifeline subscribers are.rrbje<t
lo the aon-usage requirements. ETCs subjecl lo the non-usdge requiremenls nust indicate lhe nu ber ofsubscribers de-enrolled b)'month in
Section 4. ETC| that onl)'o-ssess a Jee but do not collect suchfbes ale subject to the non-wage requirements .tn.l must also in.licate lhe nu bcr oJ'
subscri bers de-enrol led b), month.
ls the ETC subject to the non-usage requirements? Yes EI No @
ll yes, record the number ofsubscribers de-enrolled.lbr rutn-usoge hy mo th in Bbck Q below-
o
Month Subscribers De-Enrolled for Non-(Isage
January 0
Fcbruary
March 0
April 0
May 0
June 0
July 0
August 0
September 0
October 0
November 0
0
Total Subscribcrs 0
For purposcs of'this filing, an ofllcer is an occupant ofa position listed in the artiole of incorporation, articlcs oftbnnation,
or other similar legal document. An officer is a person who occupics a position specified in the corpoftitc by-laws (or
partnership agreement). and would typically bc prcsidcnt, vicc prcsidcnt for opcrations, vicc president fbr tlnance,
cornptrollcr, trcasurer, or a comparable position. If the filer is a sole proprietorship, the owner must sign thc ccrtificalion.
Initial Certification A ETCT uurtt "onplete thi! secrbn
I certify that thc 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 thc bcst of my knowledge, the company was presented with documentation of each consumcr's houschold
income and./or program-based eligibility prior to his or her cnrollmcnt in Lifclinc; and/or
B) Confirm consumer eligibility by relying upon access to a statc database and/or noticc of cligibility from the state
Lifeline administrator prior to enrolling a consumcr in the Lifclinc program.
I am an officer of the company named above. I am authorizcd to make this certification for the Study Arca Codc listed
above.
RRInitial
2
P
0
Dcccmbsr
Minimum Service Level
I certify that thc company listcd above is in compliance with the minimum scrvicc lcvcls sct lbrth in thc 47 CFR Scction
54.40u.
I am an officer of thc company narned above. I am authorized to make this certification lbr thc SACs listcd above.
Initial RR
Annual Recertifi catir.rn
Do nol leave empt blocks. l/ an ETC has nothing h reporl in o bltx:k. enter a zero.
Repon the number of Lifclinc subscribers due lbr recertification by month (January-Decembcr)A. Subscribers eligible for recertification by antlivcrsary monthB. Subscribers dc-enrolled prior to recertification artemptsC. Total numbcr ofsubscribers ETC is rcsponsiblc for rcccnifying (A-B)
.lan ,\ pr )t ar ,l un Jul sep Oct Noy De(Year
'l otal
0 0 0 0 0 0 0 0 0 0 0 0 0
II 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
State of federal databaseD. Subscribers recertitied through llT( access to state or federal database by anniversary month
t{n ihc nurlrbcr ofeli ible subsc.ibers vcrilicd lhrou h cccss to x siitc or federal database
l.'rb l\t ar Apr .run .lul Aug [rc('lbtaI
D 0 0 0 0 0 0 0 0 0 0 0
E. Name ofthe data sourcc(s) uscd to verify consunrer eligibility
ETC Direct ContactF. Subscribers contacted by ETC direcdy to recenify (You nuy also use this section to repon subscriber initiated recertificarions)
orl lhe number ofLifcline subscribcrs Ihc F: l( contaclcd dirccl 1l) obtrin rcce.liticalion ofel
C. Subscribers who failed to recertify through ETC dircct outrcach attempt
Jan Feb i\I ar Apr )la1 Jun Jul Aug s"p ()ct Yrar
Tol!l
0 0 0 0 0 0 0 0 0 0 0
th€ number of Lifcline subscribcrs dc-cnrolled due to ineli onse to fie ETC's outreach at
,Ierl lirb l'l rr Apr NI a1.'Jun Jul Aug s€p ()ct l)ec Year
Tolal
C 0 0 0 0 0 0 0 0 0 0 0
3
Feb IUar Aug
I
0
C
Rcccrtilication Methods
Jan Nl a)sep
I
oct
o 0
I
Dcc
Fl o I 0
00
H. Subscribers who rccqrtified through I].TC dircct L)ulrcach atlempl
li $c nrnlbcr ofLifelinc subscribers that successfull rcccrrificd lhro h ETC's oukeach
Third Party
[. Subscribers whosc c)igibility was rcviewed by slatc adrninisirator. third pafy adnlinistralor, or USAC
or1 lhe nurnbcr of Lileline subscribers contacled a slalc adnrinislralor, third pany adminislfttor, or USA(l li)r lhe purposo o f recerti fi cation
Name ofthird pany administrator used to verify subscribcr cligibility
USAC
K. Subscribcrs de-enlolled as a result ofa third larty recertilicalion atlerupt
R thc nunrbcr ofsubscribers as a result ofineli bilir k) outrcach fronr a srate aLlnrlristr0lor, lhrr{l prr(y adnrinislrator. or tISAC
L. Subscribers who recertified through a state administrator. third party administrator, or USAC's recertification effort
Rc thc number ofsubscribers that recenified through a requesl from a slatc adminislmtor, ftird parly administmtor. or USAC
Ccrtilication:
Recertifi cation Method: Database
I ccrtify that the company listed above has procedures in place to recertify consumer eligibility by relying on a databasc. I
am an otlicer ofthe company named above. I am authorized to make this ccrtification for the SAC(s) listed above.
Initial
Jan Feb \lar Apr lll ay Jun Jul Aug scp ()ct Drc Yrar
'l'o(al
TI 0 0 0 0 U 0 0 0 0 0 0 0 0
Jan I,cb Mar Ap.tvl ry Jrrn Jul Aug sep Ocl Dr:c 'lbtal
I 0 0 0 0 0 0 0 1 1 0 4 0 6
Jxn Apr NIryl,eb Mar Jun Jul Aug sep ()ct Dcc
'lbtal
K.0 0 0 0 0 0 0 1 0 0 1 0 2
Jan Jll ayl.el)Apt .lun Jul Aug sep ()cl Dec Ycar'lbtal
L 0 0 0 0 0 0 0 0 3 0 4
4
I
I
II
)lar
0 1 I
Recertification Method: ETC
I certify that the company listcd above has proccdures in place to recertify thc continued eligibility of all of its Lil'elinc
subscribcrs, and that, to the best ofmy knowledge, thc company obtained signed certifications from all subscribers attesting
to their continuing cligibility for Lifcline. I am an oi'ticer of the company named above. I am authorized to makc this
certification for the SAC(s) listcd above.
lnitial
Recertifi cation Method: Third Party
I certify that the company listed above has procedures in place to rcccrtify consumer eligibility by rclying on an
administrator. I am an officer ofthe company namcd above. I am authorizcd to makc this certification for the SAC(S)
listed above.
Initial RR
No Subscribers
I certify that my company did not claim federal low income support for any Lifeline subscribers for the cunent Form 555
data year. I am an officer ofthe company named above. I am authorized to make this certification for the SAC listed
above.
I n itial
\.1 = (c+K)N = (D+t+t)() = Nl/N*ll)0
Total numbcr of subscribers de-enrolled as
a rcsult of recertificalion
Total nurnbcr of subscribers ETC is
respoosible for recertifying
Perrent of sub$crib€rs due for
recertifi cation who ricrc de-enrolled
2 6 33.33%
Signature Block
By signing below, I certify that the company listcd above is in compliance with all fcdcral Lilcline certification
procedurcs, I am an officer ofthe company narred abovc. I am authorized to make this certification lor the Study
Area Code (SAC) listcd above.
Signed,
Rich Redrnan Vice President
Signaturc ofOfficer
[e-mail]
Ernail Address of Oflicer
Julie Laumb
l'crson Cornpleting This Clcnification Foml
Rich Redman Vice President
Printed Name and Title ofOfficcr
Jan 06, 2020
Dalc
208-673-2208
(lonlact Phone Numbcr
5
Alliliated ETCs
SAC Name
6