20210201I-Wireless Form 555.pdf

Annual Lifeline Eligible Telecommunications Carrier Certilication Form 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 31st (Annually)
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Does the reporting company have affiliated ETCs? Yes Eil No Eil
Provide a list of all ETCs that are afiliated with the reporting ETC, using page 4 and additional sheets if necessary. Afiliation shall be
determined in accordance with Section j(2) of the Communications Act. That Section de/ines "afiiliate" as "a Wrson 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 153(2). See also 47
c.r.a. $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
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Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Canier @TC) must provide a cenificationformfor each SAC through which it provides Lifeline service).
479020 143035427
ETC NameState
ID2020 l-Wireless LLC
Recertification Year
Access Wireless
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "N/A" Do nat lene bhnk)
Holding CompanyName
(If sane 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 monthlyfwfrom their Lifeline subs_cribers are subiect
to the non-usage requiremmts. ETCs subject to the non-usage requirements must indicate the number of subscribers de-enrolled by month in
Section 4. ETes thal only assess afee bui do not collect suchfees are subject to the non-usage requirements and must also indicate the number of
subscibers de-enrolled by month.
Is the ETC subject to the non-usage requirements? yes E[ No E[
Ifyes, record the number of subscribers de-enrolled for non-usage by month in Block Q below.
P o
Month Subscribers De-Enrolled for Non-Usage
January 1
February 0
March 4
April 0
May 0
June 0
Julv 0
Auzust 0
September 0
October 0
November 0
December 0
Total Subscribers 5
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 typically be president, vice president for operations, vice president for finance,
comptroller, treasurer, or a comparable position. If the frler is a sole proprietorship, the owner must sigrr the certification.
Initial Certificatiott All ETCs must complete this section
I certifu 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) Confirm 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.
SCInitial
2
Annual Recertification
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 recertifring (A-B)
Recertifi cation Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
the number of subscribers verified access to a state or federal
E. Name of the data source(s) used to veriry consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recerti$ (You may also use this section to report subscriber initiatod recertifications).
number of Lifeline subscribers the ETC contacted to obtain recertification of
G. Subscribers who failed to recertifu through ETC direct outreach attempt
the number of Lifeline subscribers de-enrolled due to or to the ETC's outreach
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
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
F 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
G.0 0 0 0 0 0 0 0 0 0 0 0 0
H. Subscribers who recertified through ETC direct outreach attempt
ETC's outreach
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party adminiskator, or USAC
the number ofLifeline subscribers contacted a state third or USAC for the ofrecertificatioar.
J. Name of third party administrator used to veri! 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 rhtud orUSAC.
L. Subscribers who recertified through a state adminishator, third party administrator, or USAC's recertification effort
the number ofsubscribers that recertified a from a state administrator, third or USAC
Certification:
Recertification Method: Database
I certiff 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
Aug sep Oct Nov Dec Year
Total
Jan Feb Mar Apr May Jun Jul
0 0 o 0 0 0 0H.0 0 0 0 0 0
sep Oct Nov Dec Year
Total
Jan Feb Mar Apr May Jun JUI Aug
0 0 0 0 0 0 0 0 0 0 0I.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
Nov Dec Year
Total
Jan Feb Mar Apr May Jun Jut Aug sep Oct
0 0 0 0 0 0 0 0 0 0L.0 0 0
Recertification Method: ETC
I certiff 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 signed certifications from all subscribers attesting
to their continuing eligibility for Lifeline. I am an officer of the company named above. I am authoriz,ed to make this
certification for the SAC(s) listed above.
Initial
Recertification Method: Third Party
I certifr 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.
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.
Initial
Signature Block
By signing below, I certi$ 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,
Sean Cullen, CFO Sean Cullen, CFO
Sigrature of Officer
sean.cu I [e-mail]
Email Address of Officer
Sam Bailey
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 30,2021
Date
513-550-2755
Contact Phone Number
M:(c+K)1r1 = @+F+I)O = M/I{*lfi)
Total number of subscribers de-enrolled as
a result of recertilication
Total number of subscribers ETC is
responsible for recertiflng
Percent ofsubscribers due for
recertification who were deenrolled
0 0 0.00/o
5
Affiliated ETCs
SAC Name
6