20220131Mud Lake Telephone Form 555.pdf

T (5O9) 747-26OO
F [phone]
MOSSADAMS
::rjj *r,:;:; 3l PH L: t,9 S:#;SfrsideAv6nue
Spokans, WA 992O1i"l !r^i.] r.- I ',/ri. Ilqc;fn!.l! ,'irr",rrl\/ri
VIA EilAlL: [e-mail]
January 31,2022
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
Mud Lake Telephone Cooperative Assn lnc. (SAC 472227).
An electronic version of the filing was also submitted via the FCC's website on January 31,2022.
lf you have any questions or concerns about this Certification, please contacl me.
Sincerely,
/,w-
Tym Rutkowskl
Senior Manager
(w917774137
tvm. rufl<[e-mail]
Attachment
Annual Lifellne Eltgible Telecommunicafionr Carrler Cerdffcadon tr'om All carriers must complete all or portions
of all sections Form must be submitt€d to USAC and filed with the Federal Commrmications Commission
IMPORTAITT: PLEASE READ INSTRUCTIONS FIRST
Deodline: Janaary 31n (Annually)
Does the reporting company have alfflleted ETCs? Yes E[ No E[
Prwide a lbt of all ETCs tlat are affliated with tle rqorting ETC, using pqe 4 od additional sheas if necessary. Afiliation sllr,ll be
futermircd in accordancewith Section 3Q) olthe Commwications Act. Ilat S@tion defues "afiliote" as "aperron that (directly or imlirutly)
owns or contruk, is ownd or antrolld by, or is tmdq contnon ownenhip or connol with onther poron." 47 U.S.C. S 153(2). Se also 47
c.F.x. $ 76.1200.
AffiliatedETC's SAC Affiliated ETC's Name
472227 143002519
Study Area Code (SAC) Service Provider Identification Number (SPh[)
(An Elighle Telecommtmicatilms Canier @TC) must provide a cutificationformfor cuh SAC thtoughwhich it proviiles Lifeline serrice).
2021 tD Mud Lake Telephone Cooperative Assn lnc.
Recertification Year
N/A
State ETCName
N/A
DBA, Marketing, or Other Branding Name
(If sane as EIC tune, list "N/A" Do not leave bla*)
Holding CoryanyName
(If sorcas EIVrame, list "N/A" Dorctluvebla*)
1
ETCc Subject to the Non-Usage Requlrementr
All ETCI rrarst compbte the qpopriate chq*-box. ETC.s rtat do not ossess and allca a nanthlylezfun rteir Lileline suhscribert are subject
tu rte nontsage rquiranen*. ETCs srbj@t to rte ron-usage rqubsnants must indiute thc nwtb of subscribqs de-enmlled by nonth in
Sution 4. EI1Cs rtat only assess alee but b not collecl sttchfea arc subject to the noatuage reqirenants and must also indtcate the nutber of
subscribers de-enrolld by ronth.
Is the ETC subJect to the non-usage requlrements? Yes E[ No Ell
If 1ru, record rte nwtbu of snbsoiben de-avolldfor nonasage fu month tn Block Q below.
P o
Month Subscribers De-Enrolld for Non-Usase
Januan,0
February 0
March 0
ADril 0
May 0
June 0
Julv 0
Ausust 0
September 0
October 0
Novenrber 0
December 0
Total Subscribers 0
For purposes of this filing, an officer is an ocoryant 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 agreemelrt), md would $pically be president vice president for operations, vice president for finance,
comptroller, treasurer, or a comparable position. If the filer is a sole proprietorship, the owner must sign the certification.
Initial Certificatiot Au Ercs rrntsr conpleu rtis seabn
I coti$ that the company listed above has certification procedures in place to:
A) Rwiew income and program-based eligibility documentation prior to emolling a consumer in the Lifeline prognm, and
thaf, to the best of my knowledge, the coryany was presented with documentation of each qonsumef,'s household
income and/or program-based eligibility prior to his or her enrollment in Lifeline; and/or
B) Confirm oonsumer eligibility by relying uIDn aocess to a state databose and/or notice of eligibility from the state
Lifeline administator 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.
vsInttul
2
Annual Recedlf,cedon
Do not leave a npty blocb. If an ETC lws nothing to rqort in a block, qttet a zqp.
Rs?ort ttc iltmbcr of Lifclirc subscribcrs dtrc fu roccrtification by month (Jaouary-Ihconber)
A. Subecribcm cligiblc forrcocrtifioatimby @ivErsuy EorftB. Subocribcrr dc-oollcdpriorto rcccctificdion dEry,tsC. Total numbcr of subscribat ETC ie rcspoosiblc frr rcccrtifying (.1,-S)
Receililficedon Methodr
Stete of fedent drtebueD. Subesibcrg rccrtitred fuougb EIIC ecrs b stBE tr &dcml datrbasc by mivcrsry month
Itcurnbcr mbrcdbarwifiod !oo!!s b astrE c ftdcnl dr$rrc.
E. Nam ofttc dS rorc{r) uccd o vcri$ oonrumcr cligibilit}a
ETC lXrect ConbctF. Subccribcrs cort&'tcd by ETC dkcc-tly to rccuti$ (You may also ruc thi: roctim to report rubscribcr initi*od rcccrtifcaioe),
thc mdcr of Lifclinc rubrcriban ftc EIC cffictcd to
G. Subscribcrs c,ho milcd to reccrti& fuough ETC dircct ouElacl stc,ryt
Jrn FcD Mr APr Mry Jun Jul Aug scp (H Nov I,Cc Ycer
Tohl
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
Jrn tr'eb Mer APr Mry Jun JUI Aug sGp (E Nw Ihc Ycrr
Totrl
D.0 0 0 0 0 0 0 0 0 0 0 0 0
Jrn FGb Mrr Apr Mry Jun Jd Aug sGP ft Nov IIGC Yar
Totd
F.0 0 0 0 0 0 0 0 0 00 0 0
Jrn f,'cb Mrr Apr Mey Jun Jul Aog scP Oct Nov I,GC Yerr
Totrt
G.0 0 0 0 0 0 0 0 0 0 0 0 0
3
H. Subcctibcrs v,ho r€catifid trcugh ETC direct ouhcach aficryt
tro rnmbcr ofLi$linc
Thld PertyI. Subecribcrs ufroac eligibility was revicvrcd by s[s5 adminirfrator, ftird party edminirtnator, m USAC
fu nrmbcr of Liftlinc rubgcriban cotacbd ! filc Itird cUSACfrrlho of recrtificatio.
J. Nam ofthird party adninistrator uscd to vctifr rubacribcr cligibilitf
K Subrcribcrs dc-corollcd as e result of a ftird paily rccrrtificrtim atcryt
tho runbcr of subrcribcrg !s a rcsult or 6id cUMC.
L. Subocribers u,to rccciliffcd fuorryh a stdo dminisEator, 6ftd paty ed-inif,trator, or USAC'o rcccrtificatim eftrt
tho rtdrwtifiod fimacLb cUSAC
Certlficefion:
Recer{ficedon Method: Drtebue
I c€rtify tbat the company listed above has procedures in place to rec€rtiry oonsum€r eligibility by relyrng on I dstsbase. I
am an officer ofthe coryany nsmed above. I am authorized to make this certification for the SAC(s) listed above.
Intfld
4
Jru FGb Mrr Apr Mey Jun Jd Aug scp (H Nov Ihc Yelr
Totd
H.0 0 0 0 0 0 0 0 0 0 0 0 0
APr Mry Jon Jd scp Oct Nov Ilcc Ycu
Totrl
Ju tr'eb Mer Aug
L 0 0 0 0 0 0 0 0 0 0 0 0 0
Jrn tr'cb Mrr Apr Mry Ju JUI Aug Scp (h Nov Ircc Ycer
Totrl
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Jrn FCD Mrr Apr Mry Jun Jul Aug seE Oct Nov Ilcc Ycrr
Totrl
L.0 0 0 0 0 0 0 0 0 0000
Recertlfication Method: ETC
I certiry that the coryany listed above has procedures in place to r€c€rti$, the continued eligibility of all of its Lifeline
subscribers, and that to the best of my knowledge, the cornpany obtained signed certifications from all subscrib€rs attesting
to their continuing eligibility for Lifeline. I am an officer of the coryany named above. I am authorized to make this
certification for the SAC(s) listed above.
Inidal
Recertllicadon Method: Third Perty
I certifu that the company listed above has procedures in place to recertiff oonsumer eligibility by relying on an
adminisfrator. I am an officer of the company named above. I am authorized to make this certification for the SAC(s)
listed above.
Inidst
No Subscribers
I certi$ that my company did not claim federal low income support for any Lifeline zubscribers 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 certi$ that the company listed above is in compliance wittr all fd€ral Lifeline certification
procedures. I am an officer of the coryany named above. I am authorized to make this certification for the Study
Area Code (SAC) listed above.
Signed
Valeri Steigerwald Valeri Steigerwald
Signature of Officcr
steigenrald.v@mudlake. us
Email Addrqs of Officer
Samantha Simatos
Person Coryl*ing This C.:ertification Fom
PrintedNarc and Title of Officer
Jan 31,2022
Date
208-374-il01
Contact PhoneNumb€r
5
M-(c+K)N=(D+r.+D O - lll/N*lfl)
Tohl number of rubrcrlDen de-enrollcd u
a rrrult of recerdficedon
Totrl number of rubrcrlbem ETC is
rrcponrlble for rcceldfylng
Percent ofrubccrlberr duc for
recer{iclEon who rerc de-enrolled
0 0 0.0%
Alliliated ETCs
SAC Name
5