20220126Farmers Mutual Telephone Form 555.pdf

MOSSADAMS
rr rr rrn-:-f,,iVi:U
LL^,AF{ l0r l5
T (5O9) 747-2600
F [phone]
60l W. Riversido Avonue
Sulte 18OO
Spokano, WA 99201
VIA EMAIL: [e-mail]
January 26,2022
ldaho Public Utilities Commission
Jan Norijuki
Commission Secretary
11331 W. Chinden Blvd., Bldg.8
Suite 201-A
Boise, lD 83720-0070
Re: Case No. GNR-T-22-01 ln the Matter otthe2022 Lifeline - FCC Form 555 Filing
Dear Ms. Norijuki:
Attached for filing in accordance with the above referenced proceeding is a copy of the Form 555 for
Farmers Mutual Telephone Company (SAC 472221).
An electronic version of the filing was also submitted via the FCC's website on January 18,2022.
lf you have any questions or concerns about this Certification, please contact me.
Sincerely,
/ru-
Tym Rutkowskl
Senior Manager
(5@)777-0137
tvm. [e-mail]
Attachment
Annual Lifeline Eligibte Telecommunications Carrier Certification tr'orm 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 31st (Annually)
Does the reporting company have affiliated ETCs? Yes Eil No E[
Provide a list of all ETCI that are afiliated with the reporting ETC, using page 4 and additional sheets d necessary. Afiliation shall be
determined in accordance with Section 3(2) of the Communications Act. That Section defines "afiliate" as "a person that (directly or indirectly)
oww 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
472221 143002514
Study Area Code (SAC) Service Provider Identification Number (SP[D
(An Eligible Telecommunications Carrier @TC) must provide a cetificationformfor each SAC through which it proides Lifeline service).
2021 ID Farmers Mutual Telephone Company
Recertification Year
N/A
State ETCName
DBA, Marketing, or Other Branding Name
(If sane as ETC name, list "N/A" Do rut leave blank)
Holding CompanyName
(If same as ETC name, list "N/A" Do rot leave blank)
1
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropriatc 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 ofsubscribers de-enrolled by month in
Section 4. ETCs that only assess afee but do not collecl suchfees are subject to the non-usage requirements and must also indicate the number of
subscibers de-enrolled by month.
Is the ETC subject to the non-usage requirements? yes Ell No E[
Ifyes, record the number of subscribers de-enrolled for 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
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 oflicer 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 agreement), and would tlpically 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 ETG nust complete this section
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 offrcer of the company named above. I am authorized to make this certification for the Study Area Code listed
above.
RARInitial
2
Annual Recertilication
Do not leave empty bloclu. If an ETC has nothing to rcport in a block, enter a zero.
Re,port the number of Lifeline subscribers due for recertification by month (January-December)
A. Subscribers eligible for recertification by anniversary monthB. Subscribers de-enrolledpriorto recertification attempts
C. Total number of subscribers ETC is responsible for recertifring (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified thrcugh ETC access to state or federal database by anniversary month
the number of subscribers verified access to a state or federal database.
E. Name of the data sourc{s) used to veriS consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertifu (You may also use this section to report subscriber initiatod recertifications).
the number oflifeline subscribets the ETC contacted to obain recertification
G. Subscribers who failed to recertifo through ETC direct ouheach attempt
the number ofLifeline subscribers de-enrolled due to or
3
Jan Feb Mar Apr May Jun JUI 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
Jan Feb Mar Apr May Jun Jut Aug Sep Oct Nov Dec Year
Total
D.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mer Apr May Jun Jul Aug sep Oct Nov Dec Year
Totd
F 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
G.0 0 0 0 0 0 0 0 0 0 0 0 0
H. Subscribers who recertified through ETC direct outreach attempt
ttlat recertified ETC's outreach
Third Party
I. Subscribers whose eligibility was rwiewed by state administrator, third party administrator, or USAC
the number ofLifeline subscribers contactsd a shte &ird afuinistrator or USAC for the ofrecertification-
J. Name of third party administrator used to verifl, subscriber eligibility:
K. Subscribers de-enrolled as a result of a third party recertification attempt
the number of subscribers as a result 6 !o outreach ftom a state thtud administrator or USAC
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's r€certification effort
the number ofsubscnlbers that recertified from a state lhird or USAC
Certilication:
Recertilicatlon Method: Database
I certiff that the company listed above has procedures in place to recertiff consumer eligibility by relying on a database. I
am an omcer of the company named above. I am authorized to make this certification for the SAC(s) listed above.
Initial
4
Apr May Jun JUI Aug sep Oct Nov Dec Yetr
Totd
Jan Feb Mar
0 0 0 0 0 0 0 0 0H.0 0 0 0
Jan Feb Mrr Apr May Jun JUI Aug sep Oct Nov Dec Year
Totel
0 0I.0 0 0 0 0 0 0 0 0 0 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 JUI 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 certi$ 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 signed 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
Recertilication Method: Third Party
I certiff that the company listed above has procedures in place to recertifu 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 offtcer 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.
Signed,
Ronald A Rembelski General Manage Ronald A Rembelski General M;
Signature of Officer
[e-mail]
Email Address of Officer
Krista Byrd
Person Completing This Certification Fonn
Printed Name and Title of Officer
Jan 13,2022
Date
208452-2000
Contact Phone Number
M-(G+K)N - (D+F+r)O = M/l\Itlfi)
Total number of subscrlbers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recerdfylng
Percent of subgcribers due for
recertilicrdon who were de.enrolled
0 0 0.lYo
5
Affiliated ETCs
SAC Name
6