20210127Mud Lake Telephone Form 555.pdf

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MOSSADAMS
5' ,: i:ia. ..i:bji,/l', .i:liiE$i$li
601 W. Riverside Av€nue
Suite 18OO
Spokane, WA 99201
VIA EMAIL: [e-mail]
January 27,2021
ldaho Public Utilities Commission
Jan Norijuki
Commission Secretary
11331 W. Chinden BIvd., Bldg.8
Suite 201-A
Boise, ID 83720-0070
Re: Case No. GNR-T-21-01 ln the Matter of the 2021 Lifeline - FCC Form 555 Filing
Dear Ms. Norijuki:
Attached for filing in accordance with the above referenced proceeding is a copy of the Fonn 555 for
Mud Lake Telephone Cooperative Assn. lnc. (SAC 472227).
An electronic version of the filing was also submifted via the FCC's website on January 27,2021.
lf you have any questions or concerns about this Certification, please contact me.
Sincerely,
/,rm-
Tym Rutkowski
Senior Manager
(5091777-0137
tvm. [e-mail]
Attachment
Annual Lifeline Eligible Telecommunications Carrier Certitrcation f,'orm All carriers must complete all or portions
of all sections Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTAI\T: PLEASE READ INSTRUCTIONS FIRST
Deadlke: fanuary iI* (Annually)
Does the reporting comprny have aflillated ETCs? Yes E[ No E[
Proide a lN of all ETCs tlut are qfiliated with the reporting ETC, using page 4 and additiorul sheas if nwessary. Afiliation shall be
determined in accordance with Sution j(2) of the Communications Act. That S*tion defines "afiliate" as "a person that (directly or indirutty)
owns or contnols, is owned or controlled by, or is undq common wnership or cot*ol with, another person," 47 U.S.C. S 153(2). See also 47
c.r.n $ 76.1200.
AffiliatedETC's SAC Affiliated ETC's Na:ne
1
472227 143002519
Study Area Code (SAC) Service Provider Identification Nurnber (SPDD
(An Eligible Telecommtmtcations Canier @TC) mwt provide a certificationformfor each $AC through which it provides Lifeline sewice).
2020 ID Mud Lake Telephone Cooperative Assn. lnc.
Recertification Year
N/A
State ETCNa:ne
N/A
DBA, Marketing, or Other Branding Name
(If sane as ETC name, list "N/1" Do 4leave blank)
Holding CompanyName
Qf sorcas EICtume, list'N/A" Dototleaeblank)
ETCs Subiect to the Non-Usage Requirements
All ETCI mwt complete the appropri.ate check-box. ETCs that do not assess and collect a monthlyfeefrom their Lifeline xfrscribers are subject
to the non-tuage rdquirenentit. EfCs subject to the non-usage requirernents must indicate the nuiber of subscriberc de-enrolled by month in
Section 4. ETes that only assess afee but do not collect wchfees are subject to the non-usage requirements and nust also indicate the nwnber of
subscribers de-enrolld by month.
Is the ETC subject to the non-usage requirements? Yes Eil No E[
Ifyes, record the number ofsubscribers 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
Mav 0
Jrme 0
Julv 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 by-laws (or
partnership agreement), and would tpically be president, vice president for operations, vice Fesident for finance,
comptroller, treasurer, or a comparable position. If the filer is a sole proprietorship, the owner must sip the certification.
Initial Certification, All ENs must complev 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 emolling a consumer in the Lifeline progranl 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 relyrng upon access to a state database and./or notice of eligibility from the state
Lifeline adminisfiator 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.
DKMInifial
2
Annual Recertiffcafion
Do not lean empty blocks. If an ETC has nothing to rqport ia a bloch errtet a ze?o.
Report the numbcr of Lifeline subscribcrs due for recertitrcation by month (January-December)
A Subscribers eligible for recertification by univcreory monthB. Subscrib€rs d€-€nrolled prior to recertifcation afrerytsC. Tobl number of subscrib€rg ETIC is rcsponsible forrecertifying (A-B)
Recertiffcadon Methods
Stete of federel drtebeseD. Subacribers r€c€rtified tbrough ETC acccss to sEte or fcdcral daabase by aoniversary month
verificd acces3 b r strle fi ftdcral dstabaso.
E. Name of the data sourc{e) used to vcri! consrm eligibility:
ETC Direct ContectF. Subecribers contacted by ETC directly to rccerti$ (You may also uee tLis Ecction to rrport subscriber initiated reccrtificcioas).
thc number of Lifeline subscrib€rs fte ETC cmtectcd to &tein
G. Subscribcrs who friled to r€c€rtify through ETC direct outncach attcupt
the mrmber of Liftline gubscribcrs the ETC'g outseach
3
Jrn Feb Mrr Apr Mry Jun JUI Aug sep (M Nov Ilce Yerr
TotdA0000000000000
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
Jm f,'eb Mrr Apr Mry Jun Jul Aug scp (h Nov Dcc Ycer
Totrl
D.0 0 0 0 0 0 0 0 0 0 0 0 0
Jrn Feb Mrr APr Mry Jun Jul Aug sep (h Nov Dcc Ycar
Totel
F 0 0 0 0 0 0 0 0 0 0 0 0 0
Jcn Feb Mrr Apr Mry Jul Jul Aug sep Ost Nov Ilec Yeer
Total
G.0 0 0 0 0 0 0 0 0 0 0 0 0
H. Subsmibers who recertified ftrough ETC direct oufeach atr€ryt
ETC'g odreach
Third PertyI. Subs&:rib€rs whose eligibility was reviewed by state administrator,6irdparty administsator, or USAC
thc numbcr of Lifclinc subscribers cotacbd I state &id oUSACfu6c ofrocertificdio.
J. Name of third party administrator used to veri$ aubccriber eligibilit,,:
K Subscribers dc-eorolled as a result of a ttird puty rcccrtifcation afieryt
the number of s$scrib€r8 s8 a rerult 6 bqrtstac,hftmastrtc 6id cUSAC.
L. Subs&:rib€rs qfro rec€rtifiod through a shte administrator, lhird part5r administrator, or USAC'c r€c€fiitrcation efrort
the number of gribscribcrs lfut rpc€rtifid a fio|In a strb 6id cUSAC
Certificeffon:
Recerffficaffon Method: Database
I c€rtiE, that the company listed above has procedures in place to rec€rtify consum€r eligibility by relying on a database. I
arn an officer of the company named above. I am authorized to make this certification for the SACG) listed above.
Iniflal
thet
4
Apr Mey Jun Jd Aug scp (H Nov Ilec Yeer
Totrl
Jm Feb Mrr
0 0 0 0 0H.0 0 0 0 0 0 0 0
Jen Feb Mrr APr Mry Jun JUI Aug scp Oct Nov Dec Ycrr
Totd
L 0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mr Apr Mey Jun Jut Aug sep (H Nov Dcc Ycu
Totel
K 0 0 0 0 0 0 0 0 0 0 0 0 0
Jrn Mer APr Mry Jun Jol Aug sop (b Nov Dcc Yeer
Totrl
tr'eb
0 0L.0 0 0 0 0 0 0 0 0 0 0
Recertilication Method: ETC
I certifr that the company listed above has procedures in place to recertiff 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 a make this
certification for the SAC(s) listed above.
Initiat
Recertilicatlon Method: Thlrd Party
I certiff that the company listed above has procedtres in place to recertiff consumer eligibility by relying on an
adminisEator. I am an officer ofthe company named above. I am authorized to make this certification for the SAC(s)
listed above.
Initial
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 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.
Signed
Daxrin K. May, President Danin K. May, President
Signafirc of Officer
[e-mail]
Email Address ofOffica
Danin May
Posm Corrpleting This Certification Form
Printed Name aod Title of Officer
Jan 26,2021
Date
208-374-5150
Contact Phone Number
5
M*(c+K)p*@rF+r)O = Itl/NrllX)
Totd number ofsubrcrlbcrc de-enrolled rc
a recult of recerfficedon
Totsl number of subrcribers ETC il
responrlble for recerdfylng
Percent of cubscrlberE due for
recertificetion who were deenrolled
0 0 0.0%
Affiliated ETCs
SAC Name
5