20210129Project Mutual Telephone Form 555.pdf

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Established 7976
January 28,2021
Daniel Klein
Commission Secretary
ldaho Public Utilities Commission
47 2 Wesl Wash ington Street
Boise, ldaho 83720
RE: Annual Etigibility Re-certification of Lifeline subscribers
WC Docket No. 14-171
CFO & Treasurer
PMT
507 G Street
Rupert lD 83350
cc: USAC High-Cost Low lncome Division
Federal Communication Commission
C:trua- T 2r-o I
Dear Mr. Klein
Project Mutual Telephone Cooperative Association, lnc (d/b/a pMT) of ldaho (Study Area Code4_72231) hereby provides a copy of its Annual Lifeline Eligible Telecommunications CanierCertification FCC Form 555 in compliance with 47 CFR Sq.q}as adopted by the FederalCommunication Commission (FCC) in its Lifeline Reform Order, FCC l2-ll, released February6,2012
Please note that Project Mutual Telephone Cooperative Association, lnc (d/b/a pMT) is notresponsible for recertification of Lifeline consumers in ldaho. The directions for form SS5specifically direct filers to include data for those subscribers they were responsible for certifyingAs National Verifier states, rdaho, recertifications are administeied by usAc,
lf you have questions_regarding this filing, please contact me by e-mail [e-mail] or byphone a|208-434-7124
Sincerely
fu;U-
RUPERT
507 G 5T.
RUPERT, TDAHO 83350 . ZO8-436-7t51
EURLEY
1458 OVERLAND AVE.
BURLEY TDAHO 8331S . 208-878-7151
IWIN FAILS
5O8 SHOSHONE ST. E,
TW|N rALL5, TDAHO 83301 . 208-933-71s1
WWW.PMT.ORG
l8ool322-4074
Annual Lifeline Eligible Telecommunications Carrier Certification Form All caniers 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 3lt (AnnuallY)
Does the reporting company have affiliated ETCs? Yes S No E[
provide a tisl of all ETCs that are afiliatedwith the reporting ETC, using page 4 and additional sheets if necessary. Af/iliation shall be
determined in accordance withseciion 3(2) of the Communiiations Act. Thalsecrion defines "afiliale" as "a WNon that (directly or indirectly)
owns or coltrols, is owned or controlled by, or is tmder common ou,nerchip or control with, anolher person." 47 ll'S'C' $ 153(2)' See also 47
c.r.R. $ 76.t240.
Affiliated ETC's SAC Affrliated ETC's Name
t
472231 143002521
Study Area Code (SAC)
(,4n Etigible Telecomnunications Catier (ETC) masl provide a
2020 tD
Service Provider Identification Number (SPfN)
certifi cal ion form for each SAC through which it provides Lift line semice)'
Project MutualTelephone Coop Assn lnc'
Recertification Year
N/A
State ETC Name
DBA, Marketing or Other Branding Name
(lf some as ETC name, list "N/A" Do not lea'e blank)
Holdins Companv Name
0f sane a7 ETC ttime,'list "N/A" Do not leat'e blank)
ETCs Subject to the Non-Usage Requirements
All ETCs milst complete the approptiate -check-box. El cs that do not assess and collect a m.onthlyfee fron their Lifeline subscribers are subiectto the tDn-usage rcquirement's Eics subiecr to the ,in-isagc -reqttirements muri irii*t, the number of subscribeis de-enrolled bv month ii:;,;::,,11;,flf:,!;l,f,ili;';;';f tei, oii io iot ioit;t;r;7,i;;;;;;;ik;",2"ii"'i,li,.u,osu requireients ond iist atso indicatb thi iiintiier of
Is the ETC subject to the non-usage requirements? yes Et No @l
lfyes, record tlze numbor o/subscribers de-enrolledfor non-usage by nonrh i, Block e belott,.
P
Subscribers De-Enrolled forMonth
14!uary 0
_February 0
March 0
April 0
May 0
June 0
July 0
August 0
Septgmber 0
October 0
November 0
December 0
Total Subscribers 0
Initial Certificatio n All ETCs mast contplete 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, andthat, to the best of my knowledge, the company was presented with documentation of each consumer,s householdincotne and/or program-based eligibility prior to his or her enrollment in Lifeline; and/or
B) Confirm consumer eligibility by relying upon access to a state database and/or notice of eligibility from the stateLifeline 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 listedabove.
RHInitial
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 (orpartnership agreement), and would typically be president, vice president for operations, vice president for finance,comptroller, treasurer, or a comparable position. tf ihe fiter is a soleproprietorship,ih, o*n., must sign the certification.
2
Annual Recertification
Do no! leave emply blocks. Ilan ETC has nolhing to reparl in a block, enler a zeto'
Repofi 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 recertilying (A-B)
Recertifi cation Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
tho number ol verified access to datebase.
E, Nanre of ttre data source(s) used to verify consumer eligibilityl
ETC Direct ContactF, Subscribers contacted by ETC directly lo recertiry (You may also use this section to report subscriber initiated recertifi cations).
the number of ine subscribers the ETC to obtain
C. Subscribers who failed to recertify through ETC direct outreach attempt
the of Lifeline de-enrolled due lo or to the s oulreach
3
.Ian 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
Jan Feb Mar Apr Illay Jun Jul Aug sep 0ct Nov Dec Year
Total
D,0 0 0 0 0 0 0 0 0 0 0 0 0
.Inn Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Totrl
F 0 0 0 0 0 0 0 0 0 0 0 0 0
Jan F'eb Mar Apr May Jun Jul .Aug sep Oct Nov Dec Year
Total
G 0 0 0 0 0 0 0 0 0 0 0 0 0
H.Subscribers rvho recerlified through ETC direct outreach attempt
ETC's
Third PartyI Subscribers whose eligibility rvas reviewed by state adminisrrator. third party administrator. or uSAC
thc number ofLileline subscribers contacred a state third for theor ofrecertification.
J,Name ofthird party adnrinistrator used to verify subscriber eligibility:
K.Subscribers de-enrolled as a result ofa third party recertification aflempt
the numbcr ofsubscribers as a result of or to outreach from astate third or USAC.
L.Subscribers lvho recertified through a state administrator, thind party adminisrator, or USAC's recertification efrort
the number of subscribers that recertified a a state thid USAC
Certification:
Recertification Method: Database
I certifi that the company listed above has procedures in place to recertiry consumer eligibility by relying on a database. Iam an ofncer of the company named above. I am authoriied to make thiicertification fo-r the "sAC(s) listed above.
Initial
4
Jan Fcb Mar Apr May Jun Jul Aug scp Oct Nov Dec Ycar
TI 0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb illar Apr May Jun Jul Aug sep Oct Nov Dec Year
TotalI.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr IUay Jun Jul Aug sep Oct Nov Dec Ycar
K,0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr May Jun Jul Au8 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 "o*puny obtained signed certifications from all subscribers attesting
to their continuing eligibility for Li-feline. I am an offjcei of the company narned above. I am authorized to make this
ceftification for the SAC(s) listed above.
Recertification Method: Third Party
I certify that the company listed above has procedures in place to recertifu consumer eligibili-ty. by relying 9n T -. .
administrator. I am un offi.., of the company named above. I am authoriied to make this cerlification for the SAC(s)
listed above.
Initial RH
No Subscribers
I certify that my company did not claim federal low income support for any Lifeline subscribers for the cunent Form 555
data year. I am an officer of the company named above. I am authorized to make this certification for the SAC listed
Initial
above.
Initial
M= (c+K)N = (D+F+r)O = MN*100
'l'otal numtrer of subscribers de-enrolled as
a result of rcccrtification
Total number ofsubscribers ETC is
respoasible for recertifYing
Percent of suhcribers due for
recertifi cation who were de-cnrolled
0 0 0.0%
Signature Block
Signed,
Rick Harder Treasurer
Signature of Officer
p
Ernail Address of Officer
Teresa Riedlinger
Person Completing'l'his Certification Fonn
By signing below, I certify that the company listed above is in compliance with all federal Lifeline certification
pro..iur.i. I am an officer of the company named above. I am authorized to make this certification for the Study
Area Code (SAC) listed above'
Rick Harder Treasurer
Printed Name and Title of Officer
Jan28,2021
Date
208-434-7168
Contact Phone Number
5
SAC Name
Affiliated ETCs
6