20210202Virgin Mobile USA Form 555.pdf

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RECEIVED
202lFebruary I, PM 5:17
IDAHOPUBLIC
ATILITIES COMMISSION
Suite 2400
1300 SW Fifth Avenue
Portland, OR 97201-5610
Heather toeltel
50!778-5406 tel
H eatherm oelter@d\M. com
February 1,2021
VIA E.MAIL
Jan Noriyuki
Secretary
Idaho Public Utilities Commission
Suite 201-A
I l33l W. Chinden Boulevard, Bldg. 8
Boise,Idaho 83714
[e-mail]. gov
Re:Docket GNR-T-21-01 - Virgin Mobile USA, LP - FCC Form 555
Certification Form
Dear Ms. Noriyuki:
Enclosed is a copy of Virgin Mobile USA, LP's (dba Assurance Wireless) FCC Form 555 required
to be filed with state commissions each year. Please note that the use of Virgin Mobile USA, LP's
name is solely for regulatory compliance purposes related to the ETC designation held under that
name and does not reflect any other representation. The form was timely filed with the Universal
Service Adminishative Company through the USAC's E-File System and with the Federal
Communications Commission through the FCC's Comment Filing System.
Please contact me at your convenience if you have any questions.
Sincerely,
Davis Wright Tremaine LLP
Heather Moelter
HM/Kh
DWT.COM
Demo ifi['j:::::?l]:::::::::,","",',1,]J,H:] ," rnc. http://www.apptisent.com
4850-6559{378v. I 00500334065 19
Annual Lifeline Eligible Telecommunications Carrier Certification Form All carriers must complete all or portions
of all sections Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTANIT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31* (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. ffiliation shall be
determined in accordance with Section j(2) of the Comnunications Act. That Section de/ines "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.t200.
Affiliated ETC's SAC Affiliated ETC's Name
1
479015 143033426
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier @TC) must provide a cenificationformfor each SAC through which it provides Lifeline senice'5.
2020 ID Virgin Mobile USA LP
Recertification Year
Assurance Wireless
State ETCName
Sprint Corporation
DBA, Marketing, or Other Branding Name
(If same as ETC rwmq list "N/A" Do rct leave blank)
Holding CompanyName
(If same as ETC name, list "N/A" Do not leave 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 to the non-usage requiranants 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 requirernents and must also indicate the number of
subscribers de-enrolled by month.
Is the ETC subject to the non-usage requirements? yes E[ No E[
Ifyes, record the number of subscribers de-enrolledfor non-usage by month in Block Q below.
P o
Month Subscribers De-Enrolled for Non-Usage
January 0
February 72
March 78
April 0
Mav 0
June 0
July 0
Auzust 0
Septernber 0
October 0
November 0
December 0
Total Subscribers 150
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 offrcer 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 sign 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) 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.
LWInitial
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 (January-December)
A. Subscribers eligible for recertification by anniversary monthB, Subscribers de-enrolled prior to recertificalion attemptsC. Total number of subscribers ETC is responsible for recertifuing (A-B)
Recertilication 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 recertifu (You may also use this section to report subscriber initiated recertifications).
of Lifeline subscribers the ETC contacted to obtain recertification of
G. Subscribers who failed to recertifu through ETC direct outreach attempt
the ofLifeline subscribets de-eorolled due to or to the ETC's outreach
3
Jan Feb Mar Apr May Jun Jul Aug sep 0ct 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 JUI 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
Jrn 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
subscribers that recertified ETC's outreach
Third Party
I. Subscribers whose eligibility was reviewed by state adminishator, third party administrator, or USAC
the number of Lifeline subscribers cortacted a state lhird oTUSAC forthe ofrecertification,
J. Name of third party adminishator used to veriff 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 third adminislrator oTUSAC
L. Subscribers who recertified through a state administrator, third party adminishator, or USAC's recertification effort
the number of subscriben that rece,rtified a from a state 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
Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
Jan Feb Mar
0 0 0 0 0 0 0 0 0 0H.0 0 0
sep Oct Nov Dec Year
Total
Jan Feb Mar Apr May Jun Jul Aug
0 0 0 0 0 0 0 0 0 0 0 0I.0
Jan Feb Mar Apr May Jun Jul 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.0 0 0 0 0 0 0 0 0 0 0 0 0
4
Recertification Method: ETC
I certiff that the company listed above has procedures in place to recertiff 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 officer of the company named above. I am authorized 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 recertify 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 certiff that my company did not claim federal low income support for any Lifeline subscribers for the current Form 555
datayear.I am an officer of the company named above. I am authorized to make this certification for the SAC listed
above.
Initial LW
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.
Sigred,
Larrv Weians. Vice President Larry Weians, Vice President
Sigrature of Officer Printed Name and Title of Officer
Feb 01 ,2021larry.j
Email Address of Officer
Andy M. Lancaster
Date
913-762-6107
Person Completing This Cedification Form Contact Phone Number
5
M:(c+K)yy = @+F+I)O = M/Nt100
Total number of subscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recertifying
Percent of subscribers due for
recerdfication who were de-enrolled
0 0 0.0%
SAC Name
639007 PR Wireless PR LLC
179014 T-Mobile USA lnc
199016 T-Mobile USA lnc.
219013 T-Mobile USA lnc.
269024 T-Mobile USA lnc.
289029 T-Mobile USA lnc.
369014 T-Mobile USA lnc.
449066 T-Mobile USA lnc.
499013 T-Mobile USA lnc.
52901 3 T-Mobile USA lnc.
639003 T-Mobile Puerto Rico LLC
249013 Virqin Mobile USA LP
Affiliated ETCs
6