20220112Gold Star Communications Form 555.pdf

Annual Lifeline Etigibte 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
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31* (Annually)
(L-r-ol
Does the reporting company have affiliated ETCs? Yes @ 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 AcL That Section defines "afiiliate" 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"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 Telecommunications Carrier (ETC) must provide a certificationformfor each SAC through which it provides Lifeline service).
479011 143032440
State
ID2021 Gold Star Communications LLC
ETC Name
Horizon Communications, lnc.
Recertification Year
N/A
Holding Company Name
(l/same as ETC name, list "N/A" Do not leave blank)
DBA, Marketing, or Other Branding Name
(lf same as ETC name, list "N/A" Do nollleave 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 monthlyfeefrom their Lifeline subscribers are subject
to the non-usage requirements. ETCs subject to 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 requirernents 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 number of subscibers de-enrolledfor non-usage by month in Block Q below.
P o
Month Subscribers De-Enrolled for Non-Usase
January 0
February 0
March 0
April 0
May 0
June 0
Julv 0
Auzust 0
September 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 offrcer is a person who occupies a position specified in the corporate by-laws (or
partrrership 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 Certificatioa Ail ETCs musr complete this section
I certiff that the company listed above has certification procedures in place to:
A) Review income and program-based eligibilify 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) Confirrn consumer eligibility by relying upon access to a state database and/or notice of eligibility from the state
Lifeline administrator prior to enrolling a consurner 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-December)
A. Subscribers eligible for recertification by anniversary month
B. Subscribers de-enrolled prior to recertification attemptsC. Total number of subscribers ETC is responsible for recerti$ing (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
verified access to a state or federal database.
E. Name of the data sourc{s) used to veri$ consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recerti$ (You may also use this section to report subscriber initiated recertifications).
the ETC conacted to obtain recertification of
G. Subscribers who failed to recertifu through ETC direct ouheach attempt
the number Lifeline subscribers de-enrolled due to or to the ETC's outreach
3
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Totel
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 Yeu
Totel
Jan Feb Mar Apr Mey Jun JUI Oct Nov Dec
D.0 0 0 0 0 0 0 0 0 0 0 0 0
May Jun Jul Aug sep Oct Nov Dec Yeer
Total
Jen Feb Mar APr
F 0 0 0 0 0 0 0 0 0 0 0 0 0
Apr May Jun Jut Aug sep Oct Nov Dec Year
Total
Jan Feb Mrr
G.0 0 0 0 0 0 0 0 0 0 0 00
H. Subscribers who recertified through ETC direct ouheach attempt
recertified ETC's outeach
Third Party
I. Subscribers whose eligibility was rwiewed by stare administrator, third party adminishator, or USAC
the number ofLifeline subscribers contacted a state third or USAC forthe ofrecertification,
J. Name of third party administrator used to veri$ subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number ofsubscnlbers as a result or to outeach from a stat€lhird or USAC
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number ofsubscribers lhat recertified a from a state thtud or USAC
Certification:
Recertifi cation 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
thatthe
Oct Nov Dec Year
Totel
Jan Feb Mar Apr May Jun Jul Aug sep
0 0 0 0H.0 0 0 0 0 0 0 0 0
Jan Feb Mar APr May Jun Jul Aug Sep Oct Nov Dec Year
Total
0 0 0 0 0 0 0 0 0 0I.0 0 0
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov D€c 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
4
Recertification Method: ETC
I certiS 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 authoriz,ed to make this
certification for the SAC(s) listed above.
Initial
Recertification Method: Third Party
I certi$ that the company listed above has procedures in place to recerti$ 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
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.
Initiat MM
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,
Michelle Motzkus, Leeal & Regulatol Michelle Motzkus, Legal & Regu
Signature of Officer
ma motzku s@ s i lve rsta r. net
Email Address of Officer
Bonnie Jackson
Person Corryleting This Certification Form
Printed Name and Title of Officer
Jan 10 2022
Date
307-883-601 1
Contact Phone Number
M=(C+K)11 = @+F+I)O = M/Ntlfi)
Total number ofsubscrlberc de-enrolled as
a result of recertificadon
Total number of subscribers ETC is
recponsible for recertifying
Percent ofsubscrlbers due for
recertification who were de-enrolled
0 0 0.0%
5
AffiIiated ETCs
SAC Name
472295 Columbine Teleohone Co. lnc
s19001 Silver Star Teleohone Co. lnc.
519005 Gold Star Communications LLC
512295 Silver Strar Telephone Co. lnc.
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