20220110Inland Telephone Form 555.pdf

INLAND TELEPHONE COI,iPANY
C@orate Ofrcp,s
?O3 S. 2rrd St
P.O. tux 171
Roslyn, WA 98941
riLili:ivID INIA,AIDTELEPHONE
Telephone: (W) 645-221 I
Fax: (il9) 649-3300 -rL ':alarlrlul'JlLll(
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Jarruary lO,2O22
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Idaho Rrblic Utilities Commission
Commission Secretar5r
472 W. Washington
P.O. Box 83720
Boise, ID 83720-0074
2022 Federal Lifeline Certification and Reporting
Rrrsuant to 47 C.F.R. S 54.416(b)
Dear Commission Secretar5r:
Rrrsuant to 47 C.F.R. S 54.416(b), accompanying this letter for
Iiling with the Idaho hrblic Utilities Commission ("Commission') is a copy
of the completed Federal Communications Commission ("FEC") Form 555
(Annual Lifeline Eligible Telecommunications Carrier Certification Form),
for the reporting 5rear ended December 31, 2O2L . The FCC Form 555
has been electronically submitted and certified pursuant to the FCC'S
Lifeline program rules and WC Docket No. 14-171 by Inland Telephone
Company ('CompanfXSAC 4724231to the Universd Senrice
Administrative Company and the FCC with respect to the Company's
Lifeline service subscribers residing in the State of ldatro.
Please let us know if the Commission has any questions regarding
the information presented on the accompanying form.
Sincerely,
K. Brooks
Treasurer/Controller
Accompanying document
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
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31't (Annually)
Does the reporting company have afliliated ETCs? Yes Ell 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 Cammunications 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.F.R. $ 76.t200.
Affiliated ETC's SAC Affiliated ETC's Name
472423 143002527
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Canier (ETC) must provide a certificationformfor each SAC through which it provides Lifeline service).
2021 lD lnland Telephone Company
Recertification Year
N/A
State ETC Name
Western Elite lncorporated Services
DBA, Marketing, or Other Branding Name
(lf same as ETC name, list "N/A" Do not leave blank)
Holding CompanyName
(If same as ETC name, list "N/A" Do rat leave blank)
1
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropriate check-box. ETCs that do not assess and collect a monthlyfeefron their Lifeline subscibers are subject
to the non-usage requirements. ETCs subject to the non-usage requirements must indicate the number ofsubscibers de-enrolled by month in
Section 4. ETCs that only assess afee but do not collect suchfees are subject to the non-usage requiremeats 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 subscibers 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
July 0
Auzust 0
Septernber 0
October 0
November 0
December 0
Total Subscribers 0
For purposes of this filing, an offrcer 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
parfrrership agreanent), 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 Certificatiort All ETCs must comptete this section
I certifr 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 enroltnent 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.
JKBInitial
2
Annual Recertilication
Do not leave empty blocks. 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 priorto recertification attempts
C. Total number of subscribers ETC is responsible for recertifoing (A-B)
Recertification Methods
State of federal detabaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
number of
E. Name of the data source(s) used to veriS consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertiff (You may also use this section to report subscriber initiated recertifications).
number of Lifeline
G. Subscribers who failed to recerti! through ETC direct outreach attempt
to
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 JUI Aug seP Oct Nov Dec Year
Total
D.0 0 0 0 0 0 0 0 0 0 0 0 0
Jen Feb Mer Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
0 0 0 0 0 0 0F000000
Jan Feb Mar Apr Mey Jun Jul Aug Sep Oct Nov Dec Year
Total
G.0 0 0 0 0 0 0 0 0 0 0 0 0
3
H. Subscribers who recertified through ETC direct outreach afiempt
the number ofLifeline subscribers that recertified ETC's
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number ofLifeline subscribers contacted a state administrattr third or USAC for the of recertificatim.
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 ofsubscribers as a result of or to outrreach trom a state third
L. Subscribers who recertified through a state adminishator, third party adminisuator, or USAC's recertification effort
the number ofsubscrib€rs tha recertifi€d from a state administator lhtd administrator or USAC
or USAC
a
Certilication:
Recertifr cation Method: Database
I certify that the company listed above has procedures in place to recertiff 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 Mer Apr May Jun JUI sep Oct Nov Dec Year
Totel
Aug
H.0 0 0 0 00 0 0 0 0 0 0 0
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
I.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
Tohl
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
Totel
L.0 0 0 0 0 0 0 0 0 0 0 0 0
Recertilication Method: ETC
I certifu that the company listed above has procedures in place to recertifr the continued eligibility of all of its Lifeline
subscribers, and that, to thebest of myknowledge, 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 authoriz-ed to make this
certification for the SAC(s) listed above.
Initial
Recertifrcation Method: Third Party
I certiff that the company listed above has procedures in place to recertiff 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
data year. I am an officer of the company named above. I am authorized to make this certification for the SAC listed
above.
1ai1ig1 JKB
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,
James Brooks, Treasurer James Brooks, Treasurer
Signature of Officer
j brooks@ i n la nd net. com
Email Address of OIficer
BOBBI FIELDS
Pe,rson Completing This Certification Form
Printed Name and Title of Oflicer
Jan 10,2022
Date
5096492211
Contact Phone Number
5
114:1G+K)19 = @+F+I)O = M/t{rlfi)
Total number of subscribers de-enrolled as
a result of recertificadon
Totd number of subscrlbers ETC is
responsible for recerd$ing
Percent of subscribers due for
recertification who were ds'enrolled
0 0 0.Oo/o
Affiliated ETCs
SAC Name
522423 lnland Telephone Company
5