20210113Gold Star Communications Form 555.pdf

Study Area Code (SAC) Service Provider IdentificationNumber (SPIN)
(An Eligible Telecommunications Carrier @TC) must provide a certificationformfor each SAC through which it provides Lifeline semice).
479011 143032440
State
ID2020 Gold Star Communications LLC
ETCName
Horizon Communications, lnc.
Recertification Year
N/A
Holding CompanyName
(If same as ETC name, list "N/A" Do rct leave blank)
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "N/A" Do rut leave blank)
Annual Lifeline Eligible Telecommunications Carrier Certification Form All carriers must complete all or portions
of all sections Forrn must be submitted to USAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31st (Annually)
-T-D-o I
Does the reporting company have affiliated 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 3(2) ofthe Communications Act. That Section de/ines "afliliate" as "a person that (directly or indirectly)
owns or contlols, is owned or controlled by, or is under common ownership or control with, anolher person." 47 U.S.C. S 153(2). See also 47
c.F.R S 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
r,. ;-- .,.-r l#
1i*',1 ,'
!," ':I -..'
i.;.;
{.--
l;:u'
(4,i il{
-lD 5
'\T
*1:rt
{l,#tJ }
ffi
1
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 requirements. ETCs subject to the non-usage requirements must indicate the number of subscribers 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 subiect to the non-usage requirements? yes E[ No E[
If yes, record the number of subscribers de-enrolled for non-usage by month in Block Q below.
P o
Month Subscribers De-Enrolled for Non-Usase
January 0
February 0
March 0
April 0
May 0
June 0
Julv 0
August 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 sign the certification.
Initial Certificatiotl All ETCs must complete this section
I certifu 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 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 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-December)
A. Subscribers eligible for recertification by anniversary month
B. Subscribers de-enrolled priorto 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 anniversary month
subscribers verified or federal database.
E. Name of the data source(s) used to verifu consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertifr (You may also use this section to report subscriber initiated recertifications).
the number of Lifeline ETC contacted to obtain recertification of
G. Subscribers who failed to recertiff through ETC direct outreach attempt
the number of Lifeline subscribers due to or to the ETC's
3
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
Aug Sep Oct Nov I)ec Year
Total
Mar Apr May Jun JulJanFeb
0 0 0 0 000000D.0 0 0
Nov Dec Year
Total
May Jun JUI Aug sep OctJanFebMarApr
0 0 0 0000000F000
Nov Dec Year
Total
May Jun Jul Aug Sep OctJanFebMarApr
0 0 0 0000000G.0 0 0
H. Subscribers who recertified through ETC direct outreach attempt
the number oflifeline subscribers that recertified ETC's
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number ofLifeline subscribers contacted a stat€ administrator third or USAC forthe ofrecertification.
J. Name of third party administrator used to veriry subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number ofsubscribers as a result of or to outreach from a state administator, third or USAC.
L. Subscribers who recertified through a state administrator, third party administator, or USAC's recertification effort
the number of subscribsrs that recertified a from a state administrator third administrator, or USAC
Certification:
Recertilication Method: Database
I certif, that the company listed above has procedures in place to recertiff consumer eligibility by relying on a database. I
am an offlcer of the company rurmed above. I am authorized to make this certification for the SAC(s) listed above.
Initial
4
Jan Feb Mar Apr May Jun Nov Dec Year
Totel
Jul Aug sep Oct
H.0 0 0 0 0 0 0 0 00000
Jan tr'eb Mar Apr May Jun JUI Aug Sep Oct Nov I)ec 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 Oct Nov Dec Year
Total
L.0 0 0 0 0 0 0 0 0 0 0 0 0
Recertilication Method: ETC
I certify 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
Recertification Method: Third ParW
I certify that the company listed above has procedures in place to recerti$ 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
No Subscribers
I certiS 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 MM
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.
Sigrred,
Michelle Motzkus, Legal & Regulator Michelle Motzkus, Legal& Regul
Signature of Officer
mamotzkus@silverstar. net
Email Address of Officer
Bonnie Jackson
Person Corrpleting This Certification Form
Printed Name and Title of Officer
Jan 08,2021
Date
307-883-6011
Contact Phone Number
M=(G+K)N = (D+F+r)O = M/I\t*100
Total number of subscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recertifying
Percent of subscrlbers due for
recertification who were de-enrolled
0 0 0.0o/o
5
Affiliated ETCs
SAC Name
472295 Columbine Telephone Co. lnc
519001 Silver Star Telephone Co. lnc.
519005 Gold Star Communications LLC
512295 Silver Star Telephone Co. lnc.
6