20220126Project Mutual Telephone Form 555.pdf

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6Ol W. Riversid6 Avonue
suite l800
Spokano, WA 99201
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MOSSADAMS
VIA EiiAlL: [e-mail]
January 26,2022
ldaho Public Utilities Commission
Jan Norijuki
Commission Secretary
11331 W. Chinden Blvd., Bldg.8
Suite 201-A
Boise, !D 83720-0070
Re: Case No. GNR-T-22-01 ln the Matter otlhe2022 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
Project Mutual Telephone Coop Assn lnc. (SAC 472231).
An electronic version of the filing was also submitted via the FCC's website on January 26,2022.
lf you have any questions or concems about this Certification, please contact me.
Sincerely,
/,rru-
Tym Rutkowskl
Senior Manager
[phone]
tvm. [e-mail]
Attachment
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
IMPORTAI\T: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31r. (Annually)
Does the reporting company have afliliated ETCs? Yes E[ No E[
Provide a list of all ETCs that are afiliated with the reporting ETC, using page 4 and addifional sheets if necessary. Afiliation shall be
determined in accordance with Section 3(2) of the Communications 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. { I 53(2). See also 47
c.r.R. $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
472231 143002521
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(ln Eligible Telecommunications Carrier (ETC) must provide a certificationformfor each SAC through which it provides Lifeline service).
2021 lD Project Mutual Telephone Coop Assn lnc.
Recertification Year
N/A
State ETC Name
N/A
DBA, Marketing, or Other BrandingName
(If same as ETC name, list "N/A" Do no1lleave blank)
Holding CompanyName
(If same as ETC name, list "N/A" Do not leave bhnk)
1
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropriate check-box. ETCs that do not assess and collect a monthlyfefrcm their Lifeline subscribers are subject
to the non-usage requirements. ETCs subject ta 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
subscribers de-enrolld by month.
Is the ETC subject to the non-usage requirements? Yes E[ No E[
If yes, 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 0
March 0
April 0
May 0
June 0
July 0
Auzust 0
September 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 by-laws (or
parbrership 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 Certificatiotl, All ETCs must complete this secrion
I certiff 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.
RHInitial
2
Annual Recertification
Do not leave empty bloclcs. 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-Decernber)
A. Subscribers eligible forrecertification by anniversary monthB. Subscribers de-enrolled prior to recertification attemptsC. Total number of subscribers ETC is responsible for recerti$ing (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
the number of subscribets verified acc€ss to a state or federal daabase.
E. Name of the data source(s) used to verifr consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertifr (You may also use this section to report subscriber initiated recertifications).
the numbet of Lifeline subscribers the ETC contacted to obtain
G. Subscribers who failed to recertifo through ETC direct outreach attempt
the number of Lifeline
3
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
A.0 0 0 0 0 0 0 0 0 0 0 0 0
B.0 0 0 0 0 0 0 0 0 0 0 0 0
C.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr Mey Jun Jul Aug sep Oct Nov Dec Year
Total
D.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar APr May Jun JUI Aug Sep Oct Nov Dec Year
Total
F 0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr May Jun Jut Aug sep 0ct Nov Dec Yeer
Total
G 0 0 0 0 0 0 0 0 0 0 0 0 0
H. Subscribers who recertified through ETC direct outreach attempt
Third Party
I. Subscibers whose eligibility was reviewed by state adminiskator, third party administrator, or USAC
the number of Lifeline subscribers contacted a StAt€ r,lministAtor thild or USAC for the of recertificatim.
J. Name of third party administrator used to verifr subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number ofsubscribers as a result of or to outreach from l sute sdministrator, thtd or USAC.
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number of subscribers that recertified a from a state third or USAC
Certilication:
Recertification Method: Database
I certifu that the company listed above has procedures in place to recerti$ consumer eligibility by relying on a database. I
am an ofiicer of the company named above. I am authorized to make this certification for the SAC(s) listed above.
Initial
4
Jen 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 Mer Apr May Jun JUI Aug sep Oct Nov Dec Year
Totel
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
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 Dcc Year
Totd
L.0 0 0 0 0 0 0 0 0 0 0 0 0
Recertification Method: ETC
I certiff 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 affesting
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 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 curent Form 555
data year. I am an oflicer of the company named above. I am authorized to make this certification for the SAC listed
above.
Initiat
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,
Rick Harder CFO Treasurer
Signature of Officer
Email Address of Officer
Teresa Riedlinger
Person Conpleting This Certification Form
Rick Harder CFO Treasurer
Printed Name and Title of Officer
Jan25,2022
Date
208434-7168
Contact Phone Number
5
y=14+K)1g = @+F+I)O = M/l{*lfi)
Total number of subscribers de-enrolled as
a result of recertification
Total number of subscrlbers ETC is
responslble for recertifying
Percent ofsubscribers due for
recertification who were de-enrolled
0 0 0.0Yo
Affiliated ETCs
SAC Name
6