20210113Fremont Telcom Form 555.pdf

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Communications
Lifeline Re-Certification - FCC Form iIS,=, 't. - "5;:,:iHk* , **,, .t::.. _.,; ;; { I_*il-
January 13,2021
ldaho Public Utilities Commission
472W. Washington
Boise, !D 83720
Re: WC Docket No. 14-171 and IPUC Case Number GNR-T-21-01
Fremont Telcom Co. Respectfully submits the aftached certifications pursuant to 47 CFR $54.416 (b) and
54.410 (d) as required by the Federal Communication Commission's Lifeline Reform Order. The filing has
been electronically filed in accordance ldaho Public Utilities Commission staff guidance.
Please note that Blackfoot is not responsible for recertications of Lifuline consumers in Montana or ldaho.
The directions for fonm 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 mowens@blackfoot,com or by
phone at406-541-5131.
Sincerely,
/s/ t tLcheLLe owews
Michelle Owens
Reg ulatory SpecialisUParalegal
Fremont Telcom Co.
1221N. Russe!!St.
Missoula, MT 59808
cc: USAC High Cost Low lncome Division
FCC Secretary
1221 N Russell St . Missoula, MT 59808 . 856-541-5000 . blackfootcommunications.com
Annual Lifeline Etigible 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
IMPORTANIT: PLEASE RBAD INSTRUCTIONS FIRST
Deadline: January 31* (Annually)
Does the reporting company have affiliated ETCs? Yes @ No E[
Provide a list of all ETCs that are afiliated with the reporting ETC, using page 4 and additional sheets if necessary. Affliation shall be
determined in accordance with Section 3(2) of the Communicalions Act. That Section de/ines "afiliate" as "a person that (directly or indirectly)
oww or controls, is owned or controlled by, or is under common ownership or control with, another person. " 47 U.S.C. S I 53(2). See also 47
c.F.R. $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
1.
472222 143002515
Study Area Code (SAC) Service Provider Identification Number (SPnf)
(An Eligible Telecommunications Carrier (ETC) must provide a certificationformfor each SAC through which it provides Lifeline service).
2020 lD Fremont Telcom Co.
Recertification Year
N/A
State ETCName
BTC HOLDINGS INC
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "N/A" Do rut leave blank)
Holding CompanyName
(If same as ETC name, list "N/A" Do not leave blank)
ETCs Subject to the Non-Usage Requirements
All ETCs nust complete the appropriate check-box. ETCs that do not assess and collect a monthlyfeefrom their Lifeline subscribers are subject
to the non-usage requirements- ETCs subject to the non-usage requirements must indicate the number of subscribers de-enrolled by month in
Secfion 4. ETes thal 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-enrolled for 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 offrcer 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 sigrr the certification.
Initial Certificatiol0. All ETCs nust compbte 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; and/or
B) Confrm consumer eligibility by relying upon access to a state database and/or notice of eligibility from the state
Lifeline adminisffator prior to enrolling a consumer in the Lifeline program.
I am an oflicer of the company named above. I am authorized to make this certification for the Study Area Code listed
above.
SMInitial
2
Annual Recertilication
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-Decernber)
A. Subscribers eligible for recertification by anniversary month
B. Subscribers de-enrolledpriorto recertification attempts
C. Total number of subscribers ETC is responsible for recertifring (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
E. Name of the data source(s) used to veriff consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertifu (You may also use this section to report subscriber initiated recertifications).
of Lifeline subscribers the ETC contacted to obtain recertification of
G. Subscribers who failed to recertifu through ETC direct outreach attempt
due to or to the ETC's oufeach
3
Jan Feb Mar Apr May Jun Jul Aug sep 0ct Nov Dec Year
Tofrl
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
Oct Nov Dec Year
Total
Jan Feb Mar Apr May Jun JUI Aug sep
0 000000000000D.
May Jun Jul Aug sep Oct Nov Dec Year
Total
Jan Feb Mar Apr
00000000000F00
Jun Jul Aug sep Oct Nov Dec Year
Total
Jan Feb Mar Apr May
0 0 0 0 0 0 0 0 0 0G.0 0 0
H. Subscribers who recertified through ETC direct outreach attempt
that recertified ETC's outreach
Third Party
I. Subscribers whose eligibility was reviewed by state adminishator, third party adminishator, or USAC
the number ofLifeline subscribers contacted a state administrator thid or USAC for the ofrecertification.
J. Name of third party administrator used to verit, subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number of subscribers as a result of or to outreach from a state lhird or USAC.
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number ofsubscribers that recertified from a state administrator rhid or USAC
Certification:
Recertification Method: Database
I certifr that the company listed above has procedures in place to recertiff consumer eligibility by relying on a database. I
am an officer of the company named above. I am authorized to make this certification for the SAC(s) listed above.
Initial
4
Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
Jan Feb Mar
0 0 0 0 0 0 0 0 0 0H.0 0 0
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
I.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
Year
Totel
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov I)ec
0 0 0 0 0 0 0 0 0L.0 0 0 0
Recertilication Method: ETC
I certi$ that the company listed above has procedures in place to recertifr 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
Recertification Method: Third Party
I certift that the company listed above has procedures in place to recertify 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 certiS that my company did not claim federal low income support for any Lifeline subscribers for the current Forrn 555
datayear.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 certifu 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.
Sigrred,
Stacey Mueller CFO Stacey Mueller CFO
Signature of Offrcer
[e-mail]
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
5
M=(G+K)N = (D+F+I)O =M/N*lfi)
Total number of subscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recertifying
Percent of subscribers due for
recertificrtion who were de-enrolled
0 0 0.0o/o
Affiliated ETCs
SAC Name
482235 Blackfoot Telephone Cooperative lnc.
483308 BlackfootTeleohone Coooerative lnc.
6