20220128Citizens Telecom Form 555.pdf

Ziply Fiber
4155 SWCedar Hills Blvd,
Beaverton, OR 97005
Jessica Epley
M. [phone]
[e-mail]
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January 28,2022
Mrs. Jan Noriyuki
Commission Secretary
ldaho Public Utilities Commission
472 West Washington Street
Boise, ldaho 83720
RE: Docket No. GNR-T-22-01Annual Eligibility Re-Certification of Lifeline Subscribers
Dear Mrs. Noriyuki:
Ziply Fiber of ldaho, LLC dba Ziply Fiber (Study Area Code 474427) and Ziply Fiber Northwest,
LLC dba Ziply Fiber (Study Area Code 472416) hereby provide a copy of its Annual Lifeline
Eligible Telecommunications Carrier Certification FCC Form 555 in compliance with 47 CFR
54.416 as adopted by the Federal Communication Commission (FCC) in its Lifeline Reform
Order, FCC 12-11, released February 6,2012.
Section 54.4 16(b) requires eligible telecommunication carriers (ETCs) to annually provide the
results of their re- certification efforts performed pursuant to Section 54.4 10 (f) to the FCC and
the Universal Service Administrative Company (USAC). ETCs are also required to provide the
results of their re-certification efforts to state commissions and relevant tribal governments.
Questions regarding this filing may be directed to me via email at iessigA-Cp.lCy@Zip!@ or
telephone at [phone].
Sincerely,
Jessica Epley
VP - Regulatory & External Affairs
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Annual Lifeline Eligibte Telecommunications Carrier Certilication Fom All carriers must complete all or portions
of all sections Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTAIIT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31't (Annually)
Does the reporting company have alfiliated ETCs? Yes E[ No E[
Provide a list of all ETCs that are ffiliated with the reporting ETC, using page 4 and additional sheets if necessary. Afiliation shall be
determined in accorfunce with Section 3(2) of the Communications Act. That Section defines "afiliate" as "a person that (directly or indirectly)
owns or conlrols, is owned or antrolled by, or is under common ownershtp 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
474427 143002528
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier @TC) must provide a certificationformfor each SAC through which it provides Lifeline service).
2021 ID CITIZENS TELECOMM CO OF IDAHO
Recertification Year
N/A
State ETCName
Northwest Fiber, LLC
DBA, Marketing, or Other Branding Name
(If same as ETC rame, list "N/A" Do not lene blank)
Holding CompanyName
(If same as ETC name, list "N/A" Do rct leave blank)
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ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropriate check-box. ETCs that do not dssess 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 subscribers de-enrolled by month in
Section 4. ETCs thait only assess afee but do not collect 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 E[ 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-Usaee
January 0
February 0
March 0
April 0
Mav 0
June 0
July 0
August 0
Seotember 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 oflicer is a person who occupies a position specified in the corporate byJaws (or
partnership 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 section
I certifr 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 adminisfiator 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.
BESInitial
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-Decembo)
A. Subscribers eligible for recertification by anniversary monthB. Subscribers de-enrolled prior to recertification atternptsC. Total number of subscribers ETC is responsible for recertifring (A-B)
Recertilication Methods
Stete of federal databsseD. Subscribers recertified through ETC access to state or federal database by anniversary month
to a state or fedffal
E. Name of the data sourc{s) used to veriry consumer eligibility:
ETC Direct ContectF. Subscribers contacted by ETC directly to recertiS (You may also use this section to report subscriber initiated recertifications).
of Lifeline ETC contacted to obtain
G. Subscribers who failed to recertifr through ETC direct outreach attempt
de-eorolled due to to the ETC's outreach
of
or
3
Jan Feb Mer Apr May Jun Jul Aug sep Oct Nov Dec Year
Totd
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 JUI Aug sep Oct Nov Dec Year
Totrl
D.0 0 0 0 0 0 0 0 0 0 0 0 0
May Jun Dec Yerr
Totel
Jan Feb Mar Apr JUI Aug sep Oct Nov
F 0 0 0 0 0 0 0 0 0 0 000
Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
Jrn Feb Mrr
G.0 0 0 0 0 0 0 0 0 0000
H. Subscribers who recertified through ETC direct outreach attempt
recertified ETC's oufeach
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number of Lifeline subscribers contact€d 8 State a.lministsato(third oTUSAC forthe ofrecertification.
J. Name of third party administrator used to veriry subscriber eligibility:
K. Subscribers de-enrolled as a result ofa third party recertification attempt
the number ofsubscnlbers as a result of m to ou8each fiom a state administrator, third administsator, or USAC.
L. Subscribers wtro rccertified through a state administrator, third party adminisfator, or USAC's recertification effort
the number ofsubscribers ttat recertified from a starc thtud administrator or USACa
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.
loic"t BES
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Totel
H.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr May Jun OctJulAugsep 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 Yem
Total
K.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
Totd
L.0 0 0 0 0 0 0 0 0 0 0 0 0
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Recertification Method: ETC
I certify 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 offrcer of the company named above. I am authorized to make this
certification for the SAC(s) listed above.
Initiat BES
Recertification Method: Third Party
I certifr that the company listed above has procedures in place to recertiff consumer eligibility by relying on an
administator. I am an officer of the company named above. I am authorized to make this certification for the SAC(s)
listed above.
1ai1ig; BES
No Subscribers
I certi$ that my company did not claim federal low income support for any Lifeline subscribers for the current Forrn 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 BES
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.
Sigrred,
Byron E Springer, Jr, General Counsel Byron E Springer, Jr, GeneralC<
Signature of Officer
[e-mail]
Email Address of Officer
Byron Springer
Person Coryleting This Certification Form
Printed Name ard Title of Officer
Jan26,2022
Date
2068903047
Contact Phone Number
5
M:(c+K)1r1 = @+F+I)O=M/lrl*lfi)
Total number of subscrlbers de-enrolled as
a result of recerdficafion
Total number of subscrlberu ETC is
responsible for recertifylng
Percent ofsubscriben due for
recerdficadon who were de'enrolled
0 0 0.0%
Affiliated ETCs
SAC Name
472416 Frontier Communications Northwest lnc.
532416 Frontier Communications Northwest lnc.
522416 Frontier Communications Northwest lnc.
s22449 Frontier Communications Northwest lnc.
484322 CITIZENS TELECOMM CO OF MONTANA
533401 CITIZENS TELECOMM CO OF OREGON
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