20210113Blackfoot Telephone Form 555.pdf

Btackfoot - .,.", ,., _: r i tl:,,..1-_r..'i_rVLiJ
'_ _:.iti I 3 AH ll: 5g
Communications
Lifetine Re-certification *+iCir.o lru;iH*,uuu
January 13,2021
ldaho Public Utilities Commission
472W. Washington
Boise, lD 83720
Re: WC Docket No. 14-171 and IPUC Case Number GNR-T-21-01
Blackfoot Telephone Cooperative, lnc. respectfully submits the attached certifications pursuant to 47 CFR
554,416 (b) and 54.410 (d) as required by the Federal Communication Commission's Lifeline Reform
Order. The filing has been elechonically filed in accordance 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 include data for those subscribers they were
responsible for certifying. As National Verifier states, Montana and ldaho, recertifications are administered
by USAC.
lf you have questions regarding this filing, please contact me by e-mail at [e-mail] or by
phone at 406-541 -51 31 ,
Sincerely
/s/ MLcheLLe owews
Michelle Owens
Reg ulatory SpecialisUParalegal
Blackfoot Telephone Cooperative, lnc.
1221N. RussellSt.
Missoula, MT 59808
cc: FCC Secretary
Montana Public Service Commission
USAC High Cost & Low lncome Division
Confederated Salish & Kootenai Tribes
1221 N Russell St . Missoula, MT 59808 , 866-541-5000 . blackfootcommunications.com
Annual Lifeline Eligible Telecommunications Carrier Certification Form All cariers must complete all or portions
of all sections Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTAIIT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31r" (Annually)
Does the reporting company have affiliated ETCs? Yes @ No E[
Provide a list of all ETCs that are ffiliated with the reporting ETC, using page 4 and additional sheets if necessary. Afiliation shall be
determined in accordance with Section 3(2) of the Communications Acl. That Section defines "afiliate" 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. S 1 53(2). See also 47
c.r.R..f 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
1
482235 143002531
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Canier (ETC) must proide a certificationformfor each SAC through which it provides Lifeline service).
2020 MT Blackfoot Telephone Cooperative lnc.
Recertification Year
N/A
State ETC Name
BTC HOLDINGS INC
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "N/A" Do rct leave blank)
Holding CompanyName
(If same as ETC name, list "N/A" Do rct leave blank)
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropriate check-box. ETCs that do not assess and collect a monthlyfeefrom their Lifeline subscribers are subject
to the non-usage riquiremenisl EfCs subject to the non-usage requirements must indicate the nu;;be;ofsubscibers de-enrolled by month ii
Section 4. ETCs thal only assess afee but do not collect suchfees are subject to the non-usage requirernents and must also indicate the number of
subscribers de-enrolled by month.
Is the ETC subject to the non-usage requirements? yes Eil No E[
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
May 0
June 0
July 0
Auzust 0
September 0
October 0
November 0
December 0
Total Subscribers 0
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 byJaws (or
partnership agreanent), and would typically be president, vice president for operations, vice president for finance,
comptroller, fieasurer, or a comparable position. If the filer is a sole proprietorship, the owner must sign the certification.
Initial Certificatiotl All ETCs must complete this section
I certiS 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; and/or
B) Confirm consumer eligibility by relying upon access to a state database and/or notice of eligibility from the state
Lifeline adminisfiator 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.
smInitial
2
Annual Recertification
Do not leave enpty 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 recertifting (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
the number of subscribers verified access to a state or federal database.
E. Name of the data source(s) used to verifu consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertifu (You may also use this section to report subscriber initiated recertifications).
the of
G. Subscribers who failed to recertifu through ETC direct outreach attempt
the oumber of Lifeline subscribers de-enrolled due to or to the ETC's
3
Jan Feb Mar Apr May Jun JUI Aug sep Oct Nov Dec Year
Totel
A.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
c.0 0 0 0 0 0 0 0 0 0 0 0 0
Jrn Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
0 0 0 0 0 0 0 0D.0 0 0 0 0
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Totrl
F 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
G.0 0 0 0 0 0 0 0 0 0 0 0 0
H. Subscribers who recertified through ETC direct ouheach attempt
that recertified ETC's oufeach
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party adminishator, or USAC
the number of Lifeline subscribers contacted a state third or USAC for ttre ofrecertification.
J. Name of third party administrator used to verifu subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number of subscribers as a rcsult of or to outeach from a state administrator, &ird 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 third or USAC
Certification:
Recertification Method: Database
I certifu that the company listed above has procedures in place to recertifr consumer eligibility by relying on a database. I
am an offlcer of the company named above. I am authorized to make this certification for the SAC(s) listed above.
Initial
4
Apr May Jun JuI Aug sep Oct Nov Dec Year
Total
Jan Feb Mar
0 0 0 0 0 0 0 0 0 0H.0 0 0
May Jun Jul sep Oct Nov Dec Year
Totel
Jan Feb Mar Apr Aug
I.0 0 0 0 0 0 0 0 0 0 000
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
Mar Apr May Jun Jul Aug sep Oct Nov I)ec Yerr
Total
Jan Feb
0 0L,0 0 0 0 0 0 0 0 0 0 0
Recertification Method : ETC
I certiff 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
Recertilication Method: Third Party
I certify 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 certi$ 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 Sm
Signature Block
By signing below, I certiff 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,
Stacey Mueller CFO Stacey Mueller CFO
Signature of Offrcer
sm uel le r@b lackfoot. co m
Email Address of Officer
Michelle Owens
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 12,2021
Date
406-541-5131
Contact Phone Number
y=(a+K)1rg = @+F+I)O = M/l\*lfi)
Total number of subscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recerti$ing
Percent ofsubscribers due for
recertilication who were de.enrolled
0 0 0.0o/o
5
Affiliated ETCs
SAC Name
472222 Fremont Telcom Co.
483308 BlackfootTelephone Cooperative lnc.
6