20220127Blackfoot Telephone Form 555.pdf

Blackfoot
Communications
. . ::l l:-.
Lifeline Re-Certification - FCC form565: : ii :. :,:; :..:
January 27,2022
ldaho Public Utilities Commission
472W. Washington
Boise, lD 83720
Re: WC Docket No. 14-171 and IPUC Case Number GNR-T-22-01
Blackfoot Telephone Cooperative, lnc. ("Blackfoot') respectfully submits the aftached certifications pursuant
to 47 CFR 554.416 (b) and 54.410 (d) as required by the Federal Communication Commission's Lifeline
Reform Order. The filing has been electronically filed in accordance ldaho Public Utilities Commission staff
guidance.
Please note that Blackfoot is not responsible for recertications of Lifeline consumers in Montana or ldaho.
The directions for form 555 specifically direct filers to include data for those subscribers they were
responsible for certifying. As National Verifier states, Montana and ldaho, recertifications are administered
by USAC.
lf you have questions regarding this filing, please contact me by e-mail at mowens@blackfoot,com or by
phone at 406-541-5131.
Sincerely
/s/ MLcheLLe owews
Michelle Owens
Reg ulatory SpecialisUParalegal
Blackfoot Telephone Cooperative, lnc.
1221N. RussellSt.
Missoula, MT 59808
cc: FCC Secretary
Montana Public Service Commission
USAC High Cost & Low lncome Division
Confederated Salish & Kootenai Tribes
1221 N Russell St . Missoula, MT 59808 . 865-541-5000 . blackfootcommunications.com
Annual Lifetine 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 Corununications Commission
IMPORTAI\T: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31st (Annually)
Does the reporting company have affiliated ETCs? Yes Ell No E[
Provide a list of all ETCs that are afrliated with the reporting ETC, using page 4 and additional sheets if necessary. Afiliation shall be
determined in accordancewith Section 3(2) of the Communications Act. That Section de/ines "afiliate" as "a person that (directly or indirectlf
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.r200.
Affiliated ETC's SAC Affiliated ETC's Name
482235 143002531
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Elisible Telecommunications Carrier (ETC) must provide a certificationformfor each SAC through which it provides Lifeline seruice).
2021 MT N/A
Recertification Year
N/A
State ETCName
N/A
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "N/A" Do not lene blank)
Holding CompanyName
(If same as ETC name, lisl "N/A" Do rot leove blank)
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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 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-enrolled by month.
Is the ETC subject to the non-usage requirements? yes E[ No E[
If yes, record the number of subscibers de-enrolled for 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
Julv 0
Auzust 0
September 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 formation,
or other similar legal document. An officer is a person who occupies a position specified in the corporate byJaws (or
partrership agreement), and would typically be president, vice president for operations, vice president for finance,
comptroller, treasurer, or a comparable position. If the frler is a sole proprietorship, the owner must sign the certification.
Initial Certificatiort Alt ETCs musr comptete this section
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) 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 oflicer of the company named above. I am authorized to make this certification for the Study Area Code listed
above.
SMInitial
2
Annual Recertification
Do not leave empty blocks. Ifan ETC has nothing to report in a block, enter a zero.
Report the number ofLifeline subscribers due for recertification by month (January-December)
A. Subscribers eligible for recertification by anniversary monthB. Subscribers de-enrolled prior to recertification attemptsC. Total number of subscribers ETC is responsible for recertiffing (A-B)
Recertifi cation Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
verified access to a of
E. Name of the data source(s) used to verifu consumer eligibility:
ETC Direct ContactF. Subsoibers contacted by ETC directly to recertifu (You may also use this section to report subscriber initiated recertifications).
the ETC contacted to obtain
G. Subscribers who failed to recertiry through ETC direct ouheach attempt
the subscribers de-eiuolled due to to theor
3
Jan Feb Mar Apr May Jun JUI 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 Jul Aug sep Oct Nov Dec Yctr
Total
F 0 0 0 0 0 0 0 0 0 0 0 0 0
Apr May JunJanFebMer 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
the number of Lifeline subscribers that recertified ETC's outreach
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number of Lifeline subscribers conbcted a state administrator thtud or USAC forthe of recertificatio.
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 ofsubscribers as a result of or to outreach from a state third administrator or USAC
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recertification effort
the number ofsubscribers that recertified a from a state administrator third or USAC
Certification:
Recertification Method: Database
I certifu that the company listed above has procedures in place to recertifr 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
Jen Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Totel
H 0 0 0 0 0 0 0 0 0 0 000
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 0ct Nov Dec Year
Total
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
Recertilication Method: ETC
I certiff that the company listed above has procedures in place to recerti$ 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
Recertilication 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 arn 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.
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,
Stacey Mueller CFO Stacey Mueller CFO
Signature of Officer
sm uel [e-mail]
Email Address of Officer
Michelle Owens
Person Completing This Certification Form
Printed Name and Title of Officer
Jan26,2022
Date
406-541-5131
Contact Phone Number
5
M=(G+K)N: (D+F+I)O = M/lltlfi)
Total number of subscribers de-enrolled as
a result of recerfification
Total number of subscribers ETC is
responsible for recertifying
Percent of subscribers due for
recertification who were de-enrolled
0 0 0.0o/o
Affiliated ETCs
SAC Name
472222 Fremont Telcom Co.
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