20220112Columbine Telephone Form 555.pdf

Annual Lifeline Eligible Telecommunications Carrier Certillcation 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)
-T--o?
Does the reporting company have afliliated ETCs? Yes E[ No E[
Provide a list of all ETCs that are afiiliated 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 deJines "afliliate" as "a Wrson thal (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.n. $ 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 Teleconmunications Canier @TC) must provide a certificationformfor each SAC through which it proides Lifeline service).
2021 lD Columbine Telephone Co. lnc
472295 '143011736
State ETCName
Horizon Communications, lnc
Recertification Year
N/A
Holding CompanyName
(If same as ETC name, list "N/A" Do rct leave blank)
DBA, Marketing, or Other Branding Name
(If same as ETC rnme, list "N/A" Do rwl 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 subscibers are subject
to the non-usage requirements. ETCs subject to the non-usage requirements must indicate the number of subscibers 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
sabscibers de-enrolled by month.
Is the ETC subject to the non-usage requirements? yes EE 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-Usase
Januarv 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 article of incorporation, articles of forrration,
or other similar legal document. An offrcer is a person who occupies a position specified in the corporate byJaws (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 Certificatiotl All ETCs nust complete this seaton
I certi$ 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.
MMInitial
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-Decernber)
A. Subscribers eligible for recertification by anniversary monthB. Subscribers de-errolled prior to r€c€rtification attemptsC. Total number of subscribers ETC is responsible for recertiffing (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
subscn'bers verifiod access to a state or federal &tabase.
E. Name of the data sourc{s) used to veriry consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertift (You may also use this section to report subscriber initiated recertifications).
the subscribers the ETC contacted to obain recertification of
G. Subscribers who failed to recertifu through ETC direct outreach attempt
the subscribers de-enrolled due to or to the ETC's outreach
the
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Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Tof-el
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
Apr May Jun Jul Aug sepJanFebMer Oct Nov Dec Year
Total
D.0 0 0 0 0 0 0 0 0 0 0 0 0
Apr MeyJenFebMar Jun Jul Aug sep Oct Nov Dec Year
Total
F 0 0 0 0 0 0 0 0 0 0 0 0 0
Apr May Jun JUI Aug sep Oct Nov Dec Year
Totrl
Jan Feb Mar
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 ouaeach
Third Party
L Subscribers whose eligibility was reviewed by state administrator, third party adminisaator, or USAC
the number ofLifeline subscribers contacted a sbte third administrator or USAC forthe ofrecertification.
J. Name of third party administrator used to veriry subscribo 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 administrator third administrator or USAC.
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number of subscribers that recertified i from a state lhird oTUSAC
Certilication:
Recertilication 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 offlcer 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 Mey 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 Jul Aug sep Oct Nov Dec Yeer
Total
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Jen 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
Recertilication 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 siped 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 certifi 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 certift 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 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.
Sigred,
Michelle Motzkus, Leeal & Regulator Michelle Motzkus, Legal& Regul
Signature of Officer
ma motzkus @s i lversta r. net
Email Address of Officer
Bonnie Jackson
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 10,2022
Date
307-883-601 1
Contact Phone Number
14 = (c+K)1=@+F+D O = M/'l\tlfi)
Total number of subscrlbers de-enrolled as
a result of recertification
Total number of subscrlbers ETC is
responsible for recertifying
Percent ofsubscribers due for
recertifi cation who were de-enrolled
0 0 0.0o/o
5
Affiliated ETCs
SAC Name
512295 Silver Star Telephone Co. lnc.
519001 Silver Star Telephone Co. lnc.
519005 Gold Star Communications LLC
479011 Gold Star Communications LLC
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