20210128Inland Telephone Form 555.pdf

t N LA N D TELE P H Ol,l E CO rl PANY
Corqrate Otfres
103 S.znd g,
P,O.B@( 171
Rosln,WAw94l
INLAIITDTEIEPHONE
Teleplurc: (5@) A9-221I
Fax:(il9) 6494 3(n t"
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January 28,2021
Vla ermsll ln .PD? lormat to dlsne.lolffiifuuc.lda,lw.gott
Idaho Public Utilities Commission
Cornmission Secretary
472 W. Washington
P.O. Box 83720
Boise, lD 8372O-OO74
Re 2O2l Federal Lifeline Certification and Reporting
hrrsuant to 47 C.F.R. S 54.416(b)
Dear Commission Secretary:
hrrsuant to 47 C.F.R. S 54.416(b), accompanying this letter for
filing with the Idaho Rrblic Utilities Commission ("Commission') is a copy
of the completed Federal Communications Commission ('FCC') Form 555
(Annual Lifeline Eligible Telecommunications Carrier Certification Form),
for tlre reporting year ended December 31, 2O2O. The FCC Form 555 has
been electronically submitted and certified pursuant to the FCC's Lifeline
program rules and WC Docket No. 14-171 by Inland Telephone Company
("Compan/XSAC 4724231 to the Universal Service Administrative
Company and the FCC with respect to the Company's Lifeline service
subscribers residing in the State of Idaho.
Please let us know if the Commission has any questions regarding
the information presented on the accompanying form.
Sincerely,
K. Brooks
Treasurer/Controller
Accompanying document
Annual Lifcline Etigible Tclecommunications Carrier Cefiification Form All carriers must complete all orportions
of all sections Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTAI\T: PLEASE READ INSTRUCTIONS FIRST
Deadline: Jmuary 31s (Annually)
Does the reporting compsny hsve affilieted ETCs? Yes E[ No E[
Provide a list of all ETC,s that are afiliated vith the reporting ETC, using page 4 and additioilal sheets dnecessary, Afiliation shall be
delemined in acurdance with Section 3(2) of the Communications Act. That Sedion defines "afiliate" as "a person that (directly or indirealy)
owns ol @ntrob, is owned or ontrolled by, or is wder common ownership or control with, mther person." 47 U.S.C. S 153(2). See also 47
c.F.R, i 76.1200.
Aftiliated ETC's SAC Affiliated ETC's Name
1
472423 143002527
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Teleammwications Catio (ETC) must provide a certifimtionformfor esch SAC throughwhiclt it provides Lifeline semice).
2020
Recertification Year
N/A
ID lnland Telephone Company
State ETC Name
Western Elite lncorporated Services
DBA, Marketing, or Other Branding Name
(f sarc u EIC mme, list "N/A" Do El! leave bla*)
Holding CompanyName
Qf saru u ETC mrc, list "N/A" Do not le@e blank)
ETCs Subject to the Non-Usage Requirements
All _ETCs must amplete the appropriate check-box.. ETCI that do not assess and cotlect a nonthly fee from their Lifetine subscribers are stbjectto the non-usage r,equiremills. ETC| subjecl to the non-usage requirffients m6t indi@te the nuilber'of subsoibeis de-enrolled bv month inSection-4. ETCI that-only 6sess tfee but do not callect suchfees are subject to the non-usage requireients and must also indiaie the number ofsubscribers de-enrolled by month.
Is the ETC subject to the non-usage requiremeDts? Yes EE No Ell
Ifyes, record the nwnber ofstrbscribers de-enrolledfor nona$age by nmnth in Block e betow.
P o
Month Subscribers De-Enrolled for Non-Usage
Ianuary 0
February 0
March 0
Aoril 0
Mav 0
June 0
July 0
Auzust 0
September 0
October 0
November 0
December 0
Total Subscribers 0
For purposes ofthis filing, an officer is an occupant ofa position listed in the article ofincorporation, articles offormatiorl
or other similar legal document. An officer is a person who occupies a position specified in the corporate by-laws (or
parhership agreement), and would typically be president, vice president for operations, vice president for finance,
compholler, heasurer, or a comparable position. Ifthe filer is a sole proprietorship, the owner must sign the certification.
Initial Certifi CAtiOn Ail Ercs m6t comptete this section
I certiS 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 Lifetine 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 acc€ss to a state database and/or notice ofeligibility fiom the state
Lifeline administator 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.
JKBInitial
2
Annual Recertification
Do not leave empty blocks. Ifan ETC has nothing to report in a bloch ilter a zero.
Report the number oflifeline subscribers due for recertification by month (January'December)
A. Subscribers eligible for recertification by anniversary monthB. Subscribers dc-erolled prior to r€certification attemptsC. Total number of subscribers ETC is responsible for recerti&ing (A-B)
Recertilication Methods
Strte of fcdcrrl detrbrseD. Subscribers recertified through ETC access to state or federal database by anniversary month
E. Name ofthe data source(s) used to veri$ consumer eligibility:
USAC
ETC Dircct ContactF. Subscribers contacted by ETC directly to recertiry (You may also use this section to report subsoiber initiated recertifications).
to obtain
G. Subscribers who failed to recertifu tkough ETC direct outeach attempt
duc to
3
Jen Feb Mar Apr May Jun Jul Aug sep Oct Nov Ilcc Yeer
Totrl
A.0 0 0 0 0 0 0 0 1 0 0 0 1
B 0 0 0 0 0 0 0 0 0 0 0 0 0
c.0 0 0 0 0 0 0 0 1 0 0 0 1
Jsn Feb Mar Apr May Ju Jnl Aug Scp Oct Nov Dec Year
Total
D.0 0 0 0 0 0 0 0 1 0 0 0 1
Jen Feb Mar Apr May Jun Jul Aug Scp Oct Nov Dm Year
Totel
F 0 0 0 0 0 0 0 0 0 0 0 0 0
Jrn f,'eb Mer Apr Mey Jun Jul Aug sep Oct Nov Dec Year
Totel
G.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mer Apr Mry Jun .Iul Aug Sep Oct Nov Dcc Year
Totrl
H.0 0 0 0 0 0 0 0 0 0 0 0 0
H. Subscribers u{ro recertified through ETC direct oureach attempt
the numbu ofLifelinc
Third Party
I. Subscribers vhose eligibility was reviewed by state adminishator, thtd party administrator, or USAC
the number ofLifcline subscriben contacted or USAC for the of rmertificatio.
J. Name ofthird party administatorused to verif subscribu eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number ofsubscribere x a result to outr€ch fiom a stat€third or USAC.
L. Subscribers who recertifed through a state adminishator, third party adminishator, or USAC's recertification effort
the number of subscribes from a stste sdministrator third oTUSAC
Certification:
Recertification Method: Databese
I certiff that the company listed above has procedures in place to recertifu 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.
Ioiti"t JKB
4
Jan Feb Mrr Apr May Jun Jul Aug sep Oct Nov Dec Year
Totrl
I.0 0 0 0 0 0 0 0 0 0 0 0 0
Jrn Feb M$Apr Mry Jun Jul Aug sep Oct Nov Dcc Year
Totd
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Jen Feb Mrr Apr May Jun Jul Aug sep Oct Nov Dec Yeer
Totel
L.0 0 0 0 0 0 0 0 0 0 0 0 0
Recertification Method: ETC
I certifr that the company listed above has procedures in place to recertifr the continued eligibility ofall ofis Lifeline
subscribers, and that, to the best ofmy knowledge, the company obtained sigrred certifications from all subscribers attesting
to their continuing eligibility for Lifeline. I am an officer of the company named above. I am authorized to make this
certification for the SAC(s) listed above.
Initial
Rccertification Method: Third Party
I certiff that the company listed above has procedures in place to recerti$ consumer eligibility by relying on an
adminisEator. 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 certi$ 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.
Initiel
Signature Block
By signing below, I certifr that the company listed above is in compliance with all federal Lifeline certification
procedures. I am an offrcer of the company named above. I am authorized to make this certification for the Study
Area Code (SAC) listed above.
Siped,
James K. Brooks, Treasurer James K. Brooks, Treasurer
Signature of Officer
[e-mail]
Printed Name and Title of offics
Jan 05,2021
Email Ad&ess of Offcer Date
BobbiFields 509649221 1
Pmm Conpleting This Certifiqtion Fom Contact Phone Number
y=(G+K)N = (I,+F+I)O=lWNr100
Totel number ofsubscribcrs de-cnrollcd as
r result of recertificrtion
Total number ofgubscribers ETC is
reponsiblc for necertifying
Pcrcent of$rbscribers due for
rccertificotion who wcrt deenrolled
0 1 0.0%
Affiliated ETCs
SAC Name
522423 lnland Teleohone Comoanv
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