20210113Columbine Telephone Form 555.pdf

Annual Lifeline Eligible Telecommunications Carrier Certification Form All carriers must complete all or portions
of all sections Form must be submiued to USAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31r. (Annually)-T-0-o,
Does the reporting company have alfiIiated ETCs? Yes E[ No E[
Provide a list of all ETCs that are afiliated with the reporting ETC, using page 4 and additional sheets if necessary. Afiliation shall be
determined in accordance with Section j(2) ofthe Communications Act. That Seclion de/ines "afiiliate" as "a person that (directly or indirectly)
owns or controls, is owned or controlled by, or is under conmon ownership or control with, another person." 47 U.S.C. S 153(2). See also 47
c.r.R. $ 76.t200.
Affiliated ETC's SAC Affiliated ETC's Name
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Study Area Code (SAC) Service Provider Identification Number (SPhf)
(An Eligible Telecommunications Canier @TC) must provide a certificationformfor each SAC through which it proides Lifeline sewice).
472295 143011736
State
ID2020 Columbine Telephone Co. lnc
ETCName
HORIZON COMMUNICATIONS INC
Recertification Year
N/A
Holding CompanyName
(If same as ETC name, list "N/A" Do wt leave blank)
DBA, Marketing, or Other Branding Name
(If same as ETC rame, list "N/A" Do not 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 subscrtbers are subject
to the non-usage requiremmts. ETCs subject to the non-usage requirements must indicate the number of subscibers de-enrolled by month in
Section 4. ETCs that only assess afee but do not collect suchfees are subject to the non-usage requirements and must also indicate the number of
subscribers de-enrolled by month.
Is the ETC subject to the non-usage requirements? yes E[ No E[
Ifyes, record the number of subscribers 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 agreement), and would typically be president, vice president for operations, vice president for finance,
comptroller, treasurer, or a comparable position. If the filer is a sole proprietorship, the owner must sigu the certification.
Initial Certification, All ETCs must conplete this section
I certiff 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; andlor
B) Confirm consumer eligibility by relying upon access to a state database and/or notice of eligibility from the state
Lifeline administrator 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.
MMInitial
2
Annual Recertification
Do not leave empty 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 attempts
C. Total number of subscribers ETC is responsible for recertiffing (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by aruriversary month
the number of verified access to a state or
E. Name of the data source(s) used to verifr consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertiff (You may also use this section to report subscriber initiated recertifications).
the number subscribers the ETC recertification of
G. Subscribers who failed to recerti& through ETC direct outreach attempt
the number of subscribers de-enrolled or to the ETC's outreach
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Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
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
sep Oct Nov Dec Year
Total
Apr May Jun Jul AugJanFebMar
0 0 00000000000D.
Dec Year
Total
JUI Aug sep Oct NovAprMayJunJanFebMar
0 0 000000000F00
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 outreach attempt
the number of Lifeline
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number oflifeline subscribers contacted a state third or USAC forthe ofrecertifisation-
I. Name of third party administrator used to veriry subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number ofsubscnibers as a result of or to outreach from a state third orUSAC.
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number ofsubscribers that recertified a from a state administrator lhtud admini566161 or USAC
Certification:
Recertilication Method: Database
I certiff that the company listed above has procedures in place to recertify consumer eligibility by relying on a database. I
am an offrcer of the company named above. I am authorized to make this certification for the SAC(s) listed above.
Initial
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Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
H.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan tr'eb Mar Apr May Jun JUI Aug sep Oct Nov Dec Year
Total
L 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
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr May Jun Jul Aug sep 0ct Nov Dec Year
Total
L.0 0 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 recerti$ the continued eligibility of all of its Lifeline
subscribers, and that, to the best of my knowledge, the company obtained sigrred ce(ifications from all subscribers attesting
to their continuing eligibility for Lifeline. I am an officer of the company named above. I am authoriz.ed 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 offrcer of the company named above. I am authorized to make this certification for the SAC(s)
listed above.
Initial MM
No Subscribers
I certiff 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
Signature Block
By signing below, I certify 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,
Michelle Motzkus, Leeal & Regulator Michelle Motzkus, Legal& ReguL
Sigrrature of Oflicer
mamotzkus@si lverstar. net
Email Address of Officer
Bonnie Jackson
Person Completing This Certification Form
Printed Name and Title of OfEcer
Jan 11,2021
Date
307-883-601 1
Contact Phone Number
5
M:(c+K)11 = @+F+I)O = M/N*100
Total number of subscribers de-enrolled as
a result of recertilication
Total number of subscribers ETC is
responsible for recertifying
Percent of subscribers due for
recertificrtion who were de-enrolled
0 0 0.0%
AffiIiated ETCs
SAC Name
512295 Silver Star Telephone Co. lnc.
519001 Silver Star Telephone Co. lnc.
519005 Gold Star Communications LLC
479011 Gold Star Communications LLC
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