20210201QLink Wireless Form 555.pdf

Annual Lifeline Eligible Telecommunications Carrier Certilication Form All cariers must complete all or portions
of all sections Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTA}IT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31't (Annually)
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Does the reporting company have affiliated ETCs? Yes Eil No E[
Provi.de a list of all ETCs that are ffiliated with the reponing 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 IdentificationNumber (SPIN)
(An Eligible Telecommunications Carrier @TC) must provide a certificationfonnfor each SAC through which it provides Lifeline service).
143036544479018
State
ID2020 Q Link Wireless LLC
ETCName
QUADRANT HOLDINGS GROUP LLC
Recertification Year
N/A
Holding CompanyName
(If same as ETC name, list "N/A" Do rct leove blank)
DBA, Marketing, or Other Branding Name
(If same as ETC tume, list "N/A" Do y1lleave blank)
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 ta the non-usage requirements must indicate the number of subscribers 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
subscribers de-enrolled by month.
Is the ETC subiect to the non-usage requirements? yes E[ No E[
If yes, record the number of subscibers de-enrolled for non-usage by month in Block Q below.
P o
Month Subscribers De-Enrolled for Non-Usase
January 333
February 131
March 27
April 0
May 0
June 0
July 0
Auzust 0
Septernber 0
October 0
November 0
December 0
Total Subscribers 491
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 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 Certificatiott Atl 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) 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.
IAInitial
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 month
B. Subscribers de-enrolled prior to recertification attempts
C. Total number of subscribers ETC is responsible for recertifuing (A-B)
Recertifi cation Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
subscnbers verifiod or federal database.
E. Name of the data sourc{s) used to veriry 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 ETC contacted to obtain recertification of
G. Subscribers who failed to recertifu through ETC direct outreach attempt
the number of Lifeline due to or to the ETC's outreach
3
Jan Feb Mar Apr May Jun Jut 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
Aug Sep Oct Nov Dec Year
Total
Mar Apr May Jun JulJanFeb
0 0 0 0000000D000
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
Dec Year
Total
May Jun Jul Aug Sep Oct NovJanFebMarApr
0 0 00000000G.0 0 0
H. Subscribers who recertified through ETC direct outreach attempt
the number of
Third Party
L Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number of Lifeline subscribers contacted a state third or USAC for the ofrecertification.
J. Name of third party administrator used to verifr subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number of subscribers as a result of or to outreach from a state rhid 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 thild or USAC
Certilication:
Recertification Method: Database
I certifr 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
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 Jut Aug sep Oct Nov Dec Year
Total
L 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
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan tr'eb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
L.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 recertifu 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 authorizedto make this
certification for the SAC(s) listed above.
Initial
Recertification Method: Third Party
I certiff that the company listed above has procedures in place to recertifr consumer eligibility by relying on an
administrator. I am an offrcer of the company named above. I am authorized to make this certification for the SAC(s)
listed above.
Initial
No Subscribers
I certifr 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.
Signed,
Issa Asad-CEO
Signature of Officer
I ssa@q uadrantholdings.com
Email Address of Officer
Maybell Kelly
Person Completing This Certification Form
lssa Asad-CEO
Printed Name and Title of Offrcer
Jan 29,2021
Date
8006101540
Contact Phone Number
M=(G+K)N - (D+F+I)O = M/I{*I00
Total number of subscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recertifying
Percetrt of subscribers due for
recertilication who were de-enrolled
0 0 0.0o/o
5
Affiliated ETCs
SAC Name
5