20210125Custer Telephone Broadband Form 555.pdf

Annual Lifeline Eligible Telecommunications Carrier Certilication f,'orm All carriers must complete all or portionsof all sections Form must be submitted to USAC and filed with the Federal Communications -Commission
IMPORTA}IT: PLEASE READ INSTRUCTIONS F'IRST
Deadline: January 3lst (Annually)
Does the reporting company have afliliated ETCs? yes E[ No E[
Provide a list of all ETCs that are afriliated with the reporting ETC, using page 4 and additional sheets if necessary. Afiliation shall bedetermined in accordance with Section 3(2) ofthe Communications Act. That Section de/ines "afliliate'ias "a person that (directly or indirectly)owns or controls, is owned or controlled by, or is under common ownership or control with, orrih", prrro".- lZ U.S.C. $ I5 j(2). See also 47c.F.x..f 76.1200.
Affiliated ETC's SAC ETC's Name
i irl
i;'lir ,
.-,-.
;" ,.- *
1trt#t r
tF0
/ll
t, :
i.rl
t\,t
-r)
r\}
I,]
l:,,,.;
iit-;-
$-+ l
1
479019 143031048
Study Area Code (SAC)
(An E li gib le Te lecommunic ations
Service Provider Identification Number (SPIN)
Carrier (ETC) must provide a certificationformfor each SAC through which it provides Lifeline service).
2020 ID Custer Telephone Broadband Services LLC
Recertification Year
N/A
State ETCName
Custer Telephone Cooperative, lnc.
DBA, Marketing, or Other Branding Name
(If same as ETC neme, list "N/A" Do wt leave blank)
Holding CompanyName
(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 monthlyfeefrgy ,!f::!:*lr:^"::-b:i:]f!::::,:r"!!*'
io i" ron-utog, riquiremenis. EfCs subject to the non-usage-requiremen.ts must,indicate the number oJ subscribers cle-enrollect Dy monln tn'i;;;r:;-i. Eie; tii o*ty oitiiiii"-rt ao ioi "ottea iifry"ii iri tiuiit n the non-usage requirerients and must also indicate the number of
subscribers de-enrolled by month.
Is the ETC subiect to the non-usage requirements? Yes E[ No Eil
Ifyes, record the number of subscribers de-enrolledfor non-usage by month in Block Q below.
P 0
Month Subscribers De-Enrolled for Non-
January 0
February 0
March 0
April 0
May 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 of a position listed in the article of incorporation, articles of formation,
o, ott.i similar legal document. An offrcer 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 Certificatiotl All ETCs must complete this section
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 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) Conflm 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.
Initial JDB
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 recertifring (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
of verified or federal database.
E. Name of the data source(s) used to verifu consumer eligibility:
ETC Direct Contact
F Subscribers contacted by ETC directly to recertifu (You may also use this section to report subscriber initiated recertifi cations).
the number of Lifeline the ETC to obtain
G. Subscribers who failed to recertifu through ETC direct outreach attempt
the numbsr of due to or to the ETC'S outreach
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
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total
D.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
F 0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr May Jun JUI Aug Sep Oct Nov I)ec 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 that ETC's outreach
Third Party
I. Subscribers whose eligibility was reviewed by state adminishator, third party administrator, or USAC
the number of Lifeline subscribers contacted a state thnd or USAC for the ofrecefiification.
J. Name of third party administrator used to verifr subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the numbet ofsubscribers as a result of or to outreach from a state lhtud orUSAC.
L. Subscribers who recertified through a state adminishator, third party administrator, or USAC,s recertification effort
the numbo of subscribers that recertified a &om a state lhird administrator or USAC
Certification:
Recertification Method: Database
I certi$r that the company listed above has procedures in place to recertify consumer eligibility by relying on a database. Iam an oflicer of the company named above. I am authorized to make this certification for ttre Sa-C1s;-tisted above.
Initial
4
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
TotalH.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr May Jun JUI Aug sep Oct Nov Dec Year
TotalI.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
TotalK.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
TotalL.0 0 0 0 0 0 0 0 0 0 0 0 0
Recertification 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
Recertilication Method: Third Party
I certify that the company listed above has procedures in place to recertifr 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 certify 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.
11i1ia1 JDB
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,
James Bennetts CEO James Bennetts CEO
Signature of Officer
id. ben [e-mail]
Email Address of Officer
Penon Completing This Certification Form
Printed Name and Title of Ofiicer
Jan 22,2021
Date
Contact Phone Number
5
y=(a+K)N: (D+F+I)O = M/l\*Ifi)
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
recertification who were deenrolled
0 0 0.0%
AffiIiated ETCs
SAC Name
6