20220128Inland Cellular Form 555.pdf

Annual Lifeline Eligible 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
IMPORTANIT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31a (Annually)
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Does the reporting company have afliliated ETCs? Yes Eil 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 accordance with Section 3(2) ofthe Communications Act. That Section defines "afliliate" as "a person that (directly or indirectly)
o'nns 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.n. $ 76.t200.
Affiliated ETC's SAC Affiliated ETC's Name
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479007 143037458
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carier (ETC) must provide a certificationformfor each SAC through which il provides Lifeline semice).
2021 tD N/A
Recertification Year
N/A
State ETC Name
N/A
DBA, Marketing, or Other Branding Name
(lf same as ETC name, list "N/A" Do not leave blank)
Holding CompanyName
(If same as ETC name, list "N/A" Do rnt leave blank)
I nlc^-d 0-r,\ I ..-, Lor Lr-c-
1
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropriate check-box. ETCs that do not assess and collect a monthlyfufrorn 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 nol collect suchfees are subject to the non-usage requirements and must also indicate the number of
subscrtbers de-enrolled by month.
Is the ETC subject to the non-usage requirements? Yes EE No E[
Ifyes, 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
July 0
Auzust 0
SeDtember 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 by-laws (or
partnership agreement), and would typically be president, vice president for operations, vice president for finance,
comptroller, teasuretr, or a comparable position. If the filer is a sole proprietorship, the owner must sigrr the certification.
Initial CertificatioD, Atl ETCs must complete this seaion
I certiff that the company listed above has certification procedures in place to:
A) Review income and program-based eligibility documentation priorto 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.
NWInitial
2
Annual Recertilication
Do not leave empty blocks. If an 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)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
the number subscribers verifiod access to a slate or fedeml database.
E. Name of the data sourc{s) used to veri$ consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertifi (You may also use this section to report subscriber initiated recertifications).
the number ofLifeline subscribers the ETC contacted to obtain recertification of
G. Subscribers who failed to recertiff through ETC direct outreach attempt
the number of Lifeline subscribers de-enrolled due to or to the ETC's outreach
3
Jen Feb Mer Apr May Jun JUI Aug sep Oct Nov Dec Year
Total
A.8 9 13 4 5 6 2 3 8 7 10 5 80
B.0 0 0 0 0 0 0 0 1 0 1 4 6
c 8 9 13 4 5 6 2 3 7 7 I 1 74
Jrn Mar Apr Mry JunFeb Jut Aug sep Oct Nov Dec Yeer
Total
D.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
F 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
Totel
G,0 0 0 0 0 0 0 0 0 0 0 0 0
H. Subscribers who recertified thrcugh ETC direct outreach atternpt
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number of Lifeline subscribers coftact€d a strt€ttird or USAC forthe of recertificatim.
J. Name of third party administrator used to verifo subscriber eligibility:
K. Subscribers de-enrolled as a result of a third party recertification attempt
the number ofsubscnlbers as a result or to outeach tom a starc adminisrator lhird
L. Subsoibers who recertified through a state administrator, third pany administrator, or USAC'S r€certification effort
rhe number ofsubscn"bers that recertified from a state thtud or USAC
or USAC.
a
Certilication
Recertifi cation Method: Database
I certifr that the company listed above has procedures in place to recerti$ consumer eligibility by relyrng 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.
Initiat NW
4
Jen Feb Mar Apr May Jun Jut Aug sep Oct Nov Dec Year
Total
H.0 0 0 0 0 0 0 0 0 0 0 0 0
Jrn Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Ycar
Totd
L 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
Total
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Jrn Feb Mar Apr May Jun Jut Aug Sep Oct Nov Dec Year
Tof-el
L,0 0 0 0 0 0 0 0 0 0 0 0 0
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 officer of the company narned above. I am authoriznd 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 recertifr 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 certi$ that my company did not claim federal low income support for any Lifeline subscribers for the current Forrr 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
Siguature 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.
Sigrred,
Nathan R Weis Nathan R Weis
Signature of Officer
[e-mail]
Email Address of Officer
Mike Bly
Person Corpleting This Certification Form
Printed Name and Title of Officer
Jan28,2022
Date
208-798-0245 x1222
Contact Phone Number
5
1y1 = (c+K)1r1 = @+F+I)O = M/IItlfi)
Total number ofsubscrlbers de-enrolled as
e result of recerdficedon
Total number of subscdben ETC is
responslble for reeertifying
Percent ofsubscribers due for
recerdftcaffon who were de.enrolled
0 0 0.0o/o
Affiliated ETCs
SAC Name
529003 lnland Cellular LLC
529004 lnland Cellular LLC
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