20200121Blackfoot Telephone Cooperative Form 555.pdf

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l12l No.th Russell St I Mrssoula MT 59808
866 541-5000 I Btackroot.com
RECEIVED
:020 JAN 2l All 9: 5l
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Lifeline Re-Certificalion - FCC Form 555
January 17,2020
ldaho Public Utililies Commission
472 W. Washington
Boise, lD 83720
Re: WC Docket No. 14-171 and |PUCCase NumberGNR-T-20-01
Blackfoot Telephone Cooperative, lnc. respectfully submits the attached certifications pursuant to 47 CFR
S54.416 (b) and 54.410 (d) as required by the Federal Communication Commission's Lifeline Reform Order, The
filing has been mailed in accordance with ldaho Public Utilities Commission staff guidance.
Please note that Blackfoot is not responsible for recertications of Lifeline consumers in Montana or ldaho. The
directions for form 555 specifically direct filers to only include data for those subscribers they were responsible for
certifying. Since Monlana and ldaho are National Verifier states all recertifications are administered by USAC.
lf you have questions regarding this filing please feel free to contact me by e-mail at [e-mail] or
by phone at 40&541-5131.
Sincerely,
$(
.r\
N]^-"LL Our^^l--
Michelle Owens
Regulatory Specialist
Blackfoot Telephone Cooperative, lnc.
1221 N. Russell St.
lVissoula, MT 59808
cc: FCC Secretary
Montana Public Service Commission
USAC High Cost & Low lncome Division
Confederated Salish & Kootenai Tribes
Blackfoot
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: lanuary 31* (Annually)
Does the reporting compf,try have afr iated ETCs? Yes E[ No E[
Provide a list ofall ETC9 that are afliliated with the reporting ETC, using page 4 and additional sheets if necessary. AlJiliation shall be
delermined in accordance wilh Section 3(2.1 ofthe Communicalions Act. That Seclion defrnes "aJfiliate" as "o person that (directly or indireclly)
owhs or controls, is ovned or controlled by, or is under common ownership or controlwilh, another person." 47 U-S-(:. $ 153(2). See also 47
c.F.R. I 76. t200.
Affiliated ETC's SAC A{filiated E'l'C's Name
482235 143002531
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecom unications Corrier (ETC) must provide a certiJication lorm /or each SAC through ,,ehich it prorides Lifeline sen ice)
2019 MT Blackfoot Telephone Cooperative lnc.
Recertification Year
N/A
State ETC Name
BTC HOLDINGS INC
DBA, Marketing, or Other Brandfug Name
(lf same as ETC nane, list "ll/A" Do not leave blokk)
Holding Company Name
(lf same as ETC nane, list "N/A" Do hot leatc blank)
1
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the opprcpriote check-box. ETCs that do not assess and collecl a monthly fee from theit Lifeline subscibew are subject
to the noh-ussge rcquiredents. ETC| subject to lhe non-usage requiements must indicele the number ofsubscribers de-enrolled by month in
Section 4. ETC' thal only ass*s a lee hut do not collect such fees are subject to the noh-tsage requiremehts and must also iidicote the nu ber of
subscibers de-enrolled by month.
Is the ETC subject to the non-usage requirements? Yes En No E[
fyes, record the number ofsubscribers de-enrolled for non-usage by month in Block Q belovt.
P a
Month Subscribers De-Enrolled for Non-Usage
January 0
Februarv 0
March 0
April 0
Muy 0
June 0
July 0
August 0
September 0
October 0
November 0
December 0
Total Subscribers 0
For purposes of this filing, 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 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 sigl the certification.
Initial Certification A EIcs nurt ro-ptete this seoion
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 progfim, 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; 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 c€rtification for the Study Area Code listed
above.
SMInitirl
2
lVlinimum 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 sm
Annual Recertification
Do not leove empty blocks. If an ETC has nolhing to report in a bloclL enter a zero
Report the number of Lifeline subscribers due for recertification by month (January-December)A. Subscribers eligible for recenification by arniversary monthB. Subscribers de-enrolled prior to recertification atternptsC. Total number of subscribers ETC is responsible for recetilying (A-B)
Recertifi cation Methods
Stite of federsl datsbaseD. Subscriben recertified through ETC access to state or federal database by anniversary month
thc nunlbln of subscrihcrs vcrified access to a slatc or federal database
E. Name ofthe data sourcc(s) used to verify consumer eligibility:
thc number of Lifeline subscribmi rhe EfC contacted to obtain reccnification of
G. Subscribers who failed to recertify through ETC direct outreach attempt
the numbgr of Lilcline subscnbers de-enrolle{ due to to the EIC s outreach
Jan Feb Mar Ap.IlIay .lun Jul Aug sep Oct J,tov Dec Year
Total
0 0 0 0 0 0 0 0 0 0 0 0 0
B,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 0
Jan Feb Apr May Jun Jul Aug scp Year
Total
0 0 0 0 0 0 0 0 0 0 0 0 0
.lon Feb l\,t ar Apt May Jun Jul Aug sep Oct Nov Dec Year
Total
F 0 0 0 0 0 0 000 0 0 0 0
Apr l\tay Jun Jul Aug sepFeblU ar Oct Nov Dec Year
Tot l
G 0 0 0 0 0 0 0 0 0 0000
C,
Mar Oct Dec
D,
ETC Dlrect ContactF. Subsr,ribers contacted by ETC directly to recartiry (You may also use this section to report subscriber initiated recertifications).
I
I
Jsn
H. Subscribers who recertified through ETC direct outreaoh attempt
lhe number ofLiftline subscribe6 that succcssfull rec€rlified ETC s outreach
Third PartyL Subscribers whose eligibility w&s reviewed by state administrator, third party administrator, or USAC
the number ofLilcline subscribcrs conlacled a state adfiinistrator. tl rd adminisEator. or USAC for the of recertificatim
J. Name ofthird party administrator used to verift subscribo eligibility
K- Subscribers dc-enrolled as a result ofa third party recertification aftempt
the number of subscribers as a resuh of to outreach liom a slale admhistrator, ddrd adminisfator. or USAC
L. Subscribers who rccertified through a stalc administrator, third parD, administrator. or USAC'S rcccrtification eflbrt
the number of subscriber'li that recerlified from a state adminisEator tlird administlator, or USAC
Certificetion:
Recertification Method! Datrbase
I certify that the compaly listed above has procedures il place to recertify consumer eligibility by rellng on a database. I
am an officer ofthe company named above. I am authorized to make this certification for the SAC(S) listed above.
lnitial
J.n Feb ll ar Apr Mly Jun .l ul Aug sep Oct Nov Dec Year
Totrl
H 0 0 0 0 0 0 0
lllar May Jun Jul Aug
0 0
Mar Apr May .lul Aug Nov Dec Year
Total
K,0 0 0 0 0 0 0 0 0 0 00
Jan Feb Apr NIay Jun Jul Aug sep Oct Dec Year
Toaal
L.0 0 0 0 0 0 0 0 0 0 0 0 0
4
0 0 0 0 0 0
Jsn Feb Octsee Tod In:' Io* Il;x'lo lo lo lo lo lo lo lo lo lo lo
Jsn Apr
0
l'- l'*P,t" lL
Mar Nov
Recertificrtion Method: ETC
I certify that the company listed above has procedures in place to recertiry 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
Recertifi cation Method: Third Party
I certit/ that the company listed above has procedures in place to recertifu 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 sm
No Subscribers
I certifo 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 ofthe company named above. I am authorized to make this certification for the SAC listed
above.
Initial
M = (G+K)N = (D+F+t)O = M/N*lOi)
Total number of subscribers de-edrolled as
a result of recertificrtion
Totrl number ofsubscribers ETC is
responslble for recertifyin g
Percent ofsubscribers due for
recertification who $ere de-enrolled
0 0.0%
Signature Block
By signing below, I certiff that the company listed above is in compliance with all federal Lifeline cerlification
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,
Stacey Mueller, CFO Stacey Mueller, CFO
Signature ofOfiicer
[e-mail]
Printed Namc and Title of OfEcer
Jan 17, 202Q
Email Address ofOfficer
Michelle Owens
Person Completing This Certification Form
Datc
4065415131
Contact Phone Number
5
0
Affiliated ETCs
SAC Name
Fremont Telcom Co.
483308 Blackfoot Telephone Cooperative lnc.
6