20210125Custer Telephone Cooperative Form 555.pdf

Annual Lifeline Eligible Telecommunications Carrier Certification Form All carriers must complete all or portionsof all sections Form must be submitted to USAC and filed with the Federal Communications bommissionIMPORTAI\T: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 3I* (Annually)
Does the reporting company have affiliated ETCs? yes EE No E[
Provide a list of all ETCs that are afiliated with the reporting ETC, using page 4 and additional sheets if necessary. Afiiliation shall bedetermined in accordance with Section 3(2) of the Communications Act. That Section defines "afiliate; as "o prrro, ihot (directly or indirectly)owns or controls, is owned or controlled by, or is under common ownership or control with, another person. " lZ U.S.C. $ t 53(2). See also 47c.r.R. $ 76.1200.
Affiliated ETC's SAC ETC's Name
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472218 143002512
Study Area Code (SAC)
(An Eligible Telecommunications Carrier
2020 tD
Service Provider Identification Number (SPIN)
(ETC) must provide a certificationformfor each SAC through which it provides Lifeline service).
Custer Telephone Cooperative lnc.
Recertification Year
N/A
State ETC Name
Custer Telephone Cooperative, lnc.
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "N/A" Do rat leave bla*)Holding CompanyName
(If same as ETC name, list "N/A" Do not leave blank)
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropiate check-box. ETCs that do not assess and collect a monthlyfeefrom their. Lifeline suUs,{i,b|!| 111,1uljectio i" ior-rios" riquiremenisl EfCs subject n the non-usage-requiremen.ts must.indicate the number of subscibers de-enrolled by month in-iiio, i. irei tnit onty ,;;;;;i;"-i;i n ioi iotteit su"frp"i or" *bject 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 a
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 othei 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 Certificatiol. All ETCs must complete 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) Confym 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
2
JDB
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 monthB. Subscribers de-enrolled prior to recertification attemptsC. Total number of subscribers ETC is responsible for recertifuing (A-B)
Recertilication Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
number of subscribers verified access to a state or federal database.
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).
the number oflifeline subscribers the ETC contacted to obtain
G. Subscribers who failed to recertifi through ETC direct outreach attempt
the number of Lifeline subscribers de-enrolled due to or to the
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
Apr MayJanFebMar Jun Jul Aug sep Oct Nov Dec Year
Total
F 0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Mar Apr May JunFeb JUI 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 though ETC direct outreach attempt
the number of Lifeline subscribers that recertified ETC's oufeach
Third Party
L Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number ofLifeline subscribers contacted a state third or USAC for the 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 admin'istator lhird orUSAC.
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number ofsubscribers tha recertified a from a state third or USAC
Certilication:
Recertification Method: Database
I certifr that the company listed above has procedures in place to recertify 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
Jan Feb Mar Apr May Jun Jut Aug sep Oct Nov Dec Year
Total
0 0 0 0 0 0 0 0 0 0 0 0H.0
Apr May Jun Jul Aug sep Oct Nov I)ec Year
Total
Jan Feb Mar
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
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
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 sigrred certifications from all subscribers attesting
to their continuing eligibility for Lifeline. I am an officer of the company named above. I am authorizedto 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 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 certifu 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.
1ai1is1 JDB
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,
James Bennetts CEO James Bennetts CEO
Sigrrature of Officer
jd. [e-mail]
Email Address of Officer
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 22,2021
Date
Contact Phone Number
14 = 1G+K)N = (D+F+I)O = M/Nrlfi)
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 de-enrolled
0 0 0.0o/o
5
Affiliated ETCs
SAC Name
479019 Custer Telephone Broadband Services LLC
5