20210129Potlatch Telephone Form 555.pdf

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January 29,2021
Via E-Mail: secretarv@puc. idaho.qov
Ms. Jan Norijuki
Commission Secretary
ldaho Public Utilities Commission
472W. Washington St.
Boise, lD 83720-5983
RE Case # GNR-T-21-01
FCC Form 555 Annual Lifeline Eligible Telecommunications Carrier Certification Form
for TDS Telecom
Dear Secretary Norijuki
Attached please find a copy of TDS Telecommunications LLC's ('TDS Telecom") Annual Lifeline
Eligible Telecommunications Carrier Certification Form (FCC Form 555) which was filed with the
Universal Service Administrative Company ("USAC") on January 28,2021.
TDS' FCC Form 555 included the Affiliated SACs in our filing with USAC. Due to a USAC
system issue, the affiliate information does not appear in the certified forms. We are attaching
the affiliate information with a copy of our certified Form 555 for this state notification.
lf you have any questions concerning this matter or regarding the attached information, please
contact me at 608-664-2415 or via e-mailat [e-mail].
Sincerely,
Nicole Mauritz
Regulatory Compliance Manager
Attachments
cc:Gail Long
Nez Perce Tribe
Annual Lifeline Eligible Telecommunications Carrier Certification Fom All carriers must complete all or portions
of all sections Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31't (Annually)
Does the reporting company have affiliated ETCs? Yes Eil No E[
Proide a list of all ETCs that are ffiliated with the reporting ETC, using page 4 and additional sheets if necessary. Afiiliation shall be
determined in accordance with Section 3(2) of the Communications Act. That Section delines 'afiliate" as "a person that (directly or indirectly)
owns or controls, is owned or controlled by, or is under common ownership or control with, another person. " 47 U.S.C. S I 53(2). See also 47
c.r.R. $ 76.1200.
Affiliated ETC's SAC larnnut"a ETC's Name
-- See attached worksheet -
1
472230 143002520
Study Area Code (SAC) Service Provider Identification Number (SPnf)
(An Eligible Telecommunications Carrier @TC) must provide a certi/icationformfor each SAC through which it provides Ldeline service).
2020 ID Potlatch Telephone Company lnc
Recertification Year
N/A
State ETCName
TDS Telecommunications Corporation
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "N/A" Do not leave blank)
Holding CompanyName
(If same as ETC name, list 'N/A" Do not leave bla*)
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 nuiber of subscribers de-enrolled by month ii
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 ofsubscibers de-enrolled by month.
Is the ETC subject to the non-usage requirements? yes E[ No Eil
Ifyes, record the number ofsubscribers de-enrolledfor 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
July 0
Auzust 0
Septernber 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 sigr the certification.
Initial Certification, 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) Confrm 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.
AKMInitial
2
Annual Recertification
Do not leave empty blocks. Ifan ETC has nothing to report in a block, enter a zero.
Report the number ofLifeline subscribers due for recertification by month (Ianuary-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 recertiffing (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
subscnlbers verified access to a state or federal databas€.
E. Name of the data source(s) used to veriff consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertiff (You may also use this section to report subscriber initiated recertifications).
the number of Lifeline subscribers to obtain recertifi cation
G. Subscribers who failed to recertifr through ETC direct outreach attempt
the number of Lifeline subscribsrs de-enrolled due to the ETC's ouEeach
3
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Totel
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
Nov Dec Year
Total
Mar Apr May Jun Jul Aug sep OctJanFeb
0 00000000D0000
Aug sep Oct Nov Dec Year
Total
Jan Feb Mar Apr May Jun Jul
00000000F00000
Jan Feb Mar Apr May Jun 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 through ETC direct outreach attempt
subscribers that
Third Party
I. Subscribers whose eligibility was reviewed by state adminishator, third party adminisffator, or USAC
the number ofLifeline subscribers contact€d a state third administrator oTUSAC forthe ofrecertification.
J. Name of third party administrator used to verifu subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number ofsubscribers as a result or to outreach from a state lhird administrator or USAC.
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number ofsubscribers that recertified a fiom a state lhird oTUSAC
Certification:
Recertilication Method: Database
I certiff that the company listed above has procedures in place to recertiff 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
Aug sep Oct Nov Dec Year
Total
Mar Apr Mry Jun JulJanFeb
0 0 0 0 0000000H.0 0
Nov Dec Year
Total
Apr Mry Jun JUI Aug Sep 0ctJanFebMar
0 0 0 0 0000000L00
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 I)ec Year
Total
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 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 offrcer of the company named above. I am authorizedto make this
certification for the SAC(s) listed above.
Initial
Recertilication Method: Third Party
I certifu that the company listed above has procedures in place to recertiff 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.
166a1 AKM
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.
Initial
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.
Sigrred,
Amanda Moore. Assistant Treasurer Amanda Moore, Assistant Treas
Signature of Offrcer
Ama nda. moo re@td ste leco m. com
Email Address of Offrcer
Nicole Mauritz
Person Corrpleting This Certification Form
Printed Name and Title of Officer
Jan 28,2021
Date
6086642415
Contact Phone Number
5
M=(G+K)N = (D+F+I)O = M/l{*lfl}
Total number of subscribers de-enrolled as
a result of recertilication
Total number of subscribers ETC is
responsible for recertifying
Percent ofsubscribers due for
recertification who were de-enrolled
0 0 0.0%
Affiliated ETCs
SAC Name
6
Attachment - TDS Telecommunications LLC Affiliates
SAC Name SAC Name
100005 Cobbosseecontee Telephone Companv
100007 The lsland Telephone Company
100010 Hampden Teleohone Comoanv
10001 1 Hartland & St. Albans Telephone Company
100024 Somerset Telephone Companv
100031 Warren Telephone Company
100034
The West Penobscot Telephone and Telegraph
Comoanv
109002 U.S. Cellular
120045 Kearsarge Telephone Company
120047 Menimack Countv Telephone Companv
120049 Union Telephone Company
120050 Wilton Telephone Companv. lnc.
123321 Hollis Telephone Company, lnc.
129002 NH #1 Rural Cellular. lnc. (U.S. Cellular)
140058 Ludlow Telephone Com pany
140061 Northfield Teleohone Comoanv
140062 Perkinsville Telephone Company. lnc.
1 50089 Deposit Telephone Company, lnc.
1 50092 Edwards Telephone Company, lnc.
1501'.t4 Oriskanv Falls Telephone Corooration
't501 18 Port Byron Teleohone Companv
1 501 29 Townshio Teleohone Comoanv. lnc.
1 s01 33 Vernon Telephone Company, lnc.
1 701 83 Mahanov & Mahantanqo Teleohone Comoanv
170206 Suqar Vallev Telephone Comoanv
190217 Amelia Telephone Corporation
190253 Virqinia Telephone Companv
193029 New Castle Telephone Co.
209005 Hardy Cellular Telephone Company (U.S. Cellular)
210338 Quincy Telephone Companv (FL)
220338 Quincy Telephone Comoanv (GA)
220346 Blue Ridqe Telephone Company
220351 Camden Telephone and Teleoraoh Comoanv. lnc.
220375 Nelson-Ball Ground Telephone Comoanv
239006 Wilmington Cellular Telephone Company
240533 McClellanville Telephone Company, lnc.
240535 Norwav Teleohone Co. lnc
240544 St. Stephen Telephone Company
240551 Williston Telephone Company
250284 Butler Telephone Companv, lnc.
250311 Oakman Telephone Company, lnc.
250314 Peoples Telephone Companv, lnc.
3t0677 lsland Teleohone Comoanv
310685 Chatham Telephone Companv
3to726 Shiawassee Teleohone Comoanv
310738 Wolverine Telephone Companv
320744 Camden Telephone Company, lnc.
320776 Communications Corporation of lndiana
320777
The Home Telephone Company of Pittsboro,
lnc.
320778 Home Teleohone Comoanv. lnc.
320788
The Merchants and Farmers Telephone
Comoanv
320809
Communications Corporation of Southern
lndiana
320816 S & W Telephone Companv, lnc.
320829 Tipton Telephone Companv, lnc.
320830 Tri-Countv Comm unications Corporation
320837 West Point Telephone Companv
330844 Badoer Telecom. LLC
330849 Black Earth Telephone Company, LLC
330851 Bonduel Telephone Company, LLC.
330856
Burlington, Brighton & Wheatland Telephone
Comoanv. LLC
3308s9 Central State Telephone Company, LLC
330875 Dickewille Telephone, LLC
330880 The Farmers Teleohone Companv. LLC
330881 Mid-Plains Teleohone, LLC
330909 Midwav Teleohone Comoanv. LLC
330914 EastCoast Telecom of Wisconsin, LLC
330915 Mosinee Telehphone Company
3309L7 Mt. Vemon Telephone Company. LLC
330930 Grantland Telecom, LLC
330943 Riverside Telecom, LLC
33094s Scandinavia Telephone Company, LLC
330952 Southeast Telephone Co. of Wisconsin. LLC
330954
Stockbridge & Sherwood Telephone Company,
LLC
330955 State Lonq Distance Teleohone Comoanv
330958 Tennev Teleohone Company. LLC
330963 Utelco, LLC.
330968 Waunakee Telephone Companv. LLC.
339007 United States Cellular Operating Company, LLC
359015
Farmers Cellular Telephone Company, lnc.
(U.S. Cellular)
351350 Arvig Telephone Company
351362 Bridoe Water Teleohone Co.
351413 KMP d/b/a Mid-State Telephone Companv
361433 Mid-State Telephone Companv
351507 Winsted Telephone Company
Attachment - TDS Telecommunications LLC Affiliates
260411 Leslie Countv Teleohone Comoanv
260412 Lewisport Telephone Co.
260417 Salem Telephone Co.
280448 Calhoun Citv Telephone Comoany, lnc.
283301 Southeast Mississiooi Teleohone Comoanv. lnc.
287449 Mvrtle Teleohone Comoanv. lnc.
290559 Concord Telephone Exchange, lnc
290566 Humohrevs Countv Teleohone Comoanv
290575 Tennessee Telephone Company
290578 Tellico Teleohone Comoanv. lnc.
299010
United States Cellular Operating Company of
Knoxville
300585 Arcadia Telephone Company
300607 Continental Telephone Company
300613 Little Miami Communications Corporation
300645 Oakwood Teleohone Comoanv
300662 The Vanlue Telephone Company
310672 Communications Corporation of Michigan
43L984 Oklahoma Communication Svstems. lnc.
4320t0 Mid-America Telephone, lnc.
452t7L Arizona Teleohone Comoanv
452L74 Southwestern Telephone Com pany
462L84 Delta County Tele-Comm, lnc.
462207 Strasburq Teleohone Comoanv
472230 Potlatch Telephone Company, lnc.
522404 Asotin Telephone Company (WA)
522427 Lewis River Telephone Companv, lnc.
522430 McDaniel Telephone Company
529001
McDaniel Cellular Telephone Company (U.S.
Cellular)
532404 Asotin Telephone Company (OR)
539002 USCOC of Oregon RSA #5, lnc. (U.S. Cellular)
54232L Happv Vallev Telephone Companv
542322 Hornitos Teleohone Comoanv
542323 Winterhaven Telephone Companv