20210201Inland Cellular 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
IMPORTAI\T: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31't (Annually)
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Does the reporting company have afliliated ETCs? Yes E[ No E[
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 3(2) of the Communications Act. That Section defines "ffiliate" 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 153(2). See also 47
c.r.R. $ 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 proide a certificationformfor each SAC through which it provides Lifeline service).
479007 143037458
ID
State
2020 lnland Cellular LLC
Recertification Year
N/A
ETC Name
lnland Cellular Telephone Company
Holding CompanyName
(If sane as ETC name, list "N/A" Do wt leate blank)
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "N/A" Do rct lene blank)
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropiate check-box. ETCs that do not assess and collect a monthlyfeefrom their Lifeline subscrtbers are subject
to the non-usage requirements. ETCs subject to the non-usage requirements must indicate the number ofsubscribers de-enrolled by month in
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 of
subscibers de-enrolled by month.
Is the ETC subject to the non-usage requirements? yes E[ No E[
Ifyes, record the nurnber 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
June 0
Julv 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 anicle 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 agreernent), 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 sign the certification.
Initial Certilicatiotr Att ETCs must comptete this seaton
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) 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.
NWInitial
2
Annual Recertilication
Do not leave empty blocles. If an 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 attempts
C. Total number of subscribers ETC is responsible for recertifring (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
the verified access to a state or federal
E. Name of the data source(s) used to verifr consumer eligibility:
ETC Direct ContectF. Subscribers contacted by ETC directly to recertiff (You may also use this section to report subscriber initiated recertifications).
the number oflifeline 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 JUI Aug sep Oct Nov Dec Year
Total
A.5 1 1 2 0 1 2 0 39 7 0 5 63
B.3 0 0 1 0 0 0 0 4 0 0 0 I
C.2 1 1 1 0 1 2 0 35 7 0 5 55
Apr MayJanFebMar 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 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
the number of Lifeline subscribers that recertified ETC's outreach
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number oflifeline subscribers contacted a stat€third or USAC for the ofrecertification.
Name of third party administrator used to verifu subscriber eligibility:
USAC
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the numbet ofsubscribers as a result of or to outreach from a stat€6id orUSAC.
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number ofsubscribers that recertified a from a state thftd oTUSAC
Certification
Recertification Method: Database
I certiff that the company listed above has procedures in place to recerti$ 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
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
H.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
L 2 1 1 1 0 1 2 0 35 7 0 5 55
Jan Feb Mar Apr May Jun JUI Aug sep Oct Nov Dec Year
Totrl
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 Dec Year
Total
L.2 1 1 1 0 1 2 0 35 7 0 5 55
Recertification 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 thebest ofmy 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 certify 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 NW
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 ofiicer 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.
Sigrred,
Nathan R. Weis Nathan R. Weis
Signature of Offrcer
[e-mail]
Printed Name and Title of Officer
Jan 22,2021
Email Address of Officer
Mike Bly
Date
2087980245
Person Completing This Certification Form Contact Phone Number
5
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Total number of subscribers de-enrolled as
a result of recerfification
Total number of subscribers ETC is
responsible for recertifying
Percent of subscribers due for
recertification who were de-enrolled
0 55 0.0%
AffiIiated ETCs
SAC Name
529003 lnland Cellular LLC
529004 lnland Cellular LLC
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