20220131Potlatch Telephone Form 555.pdf

i'lhe-lVEil
RE
,,'. .i;,i, i I PH 3: l+2
January 31,2022
Via E-Mai!: [e-mail]
Ms. Jan Norijuki
Commission Secretary
ldaho Public Utilities Commission
472W. Washington St.
Boise, lD 83720-5983
Case # GNR-T-22-01
FCC Form 555 Annual Lifeline Eligible Telecommunications Carrier Certification Form
for TDS Telecom
Dear Secretary Norijuki:
Attached please find a copy of TDS Telecommunications LLC's (TDS Telecom') Annual Lifeline
Eligible Telecommunications Carrier Certification Form (FCC Form 555) which was filed with the
Universa! Service Administrative Company ('USAC") on January 31,2022.
TDS' FCC Form 555 included the Affiliated SACs in our filing with USAC. Due to a USAC
system issue, the affiliate information does not appear in the certified forms. We are attaching
the affiliate information with a copy of our certified Form 555 for this state notification.
!f you have any questions concerning this matter or regarding the attached information, please
contact me at 608-664-2415 or via e-mail at [e-mail].
Sincerely,
Nicole Mauritz
Regulatory Compliance Manager
Attachments
Gail Long
Nez Perce Tribe
cc:
Annual Lifeline Eligible Telecommunications Carrier Certification tr'orm All carriers must complete all or portions
of all sections Fonn 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 alliliated 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 accordance with Section 3(2) of the Commwicotions Act. That Section defines 'afiliate" as "a person that (directly or indirectly)
owns or controls, is owned or conlrolled by, or is wtder common ownership or control with, anolher person. " 47 U.S.C. S I 53(2). See also 47
c.r.n $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
472230 143002520
Study Area Code (SAC) Service Provider Identification Number (SPhf)
(An Elisible Telecommunications Carrier @TC) must provide a certificafionformfor each SAC through which it provides Lifeline service).
2021 ID Potlatch Telephone Company lnc
Recertification Year
N/A
State ETCNa:ne
Telephone and Data Systems, lnc.
DBA, Marketing, or Other Branding Name
(If same as ETC name, list "N/A" Do rut leave blank)
Holding CompanyName
(If sane as ETC name, list "N/4" Do tnt leave blank)
1
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropiate check-box. ETCs that do not assess 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 ofsubscribers de-enrolled by month in
Seaion 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 monrt.
Is the ETC subject to the non-usage requirements? Yes Ell No E[
Ifyes, record the number of subscribers 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 byJaws (or
parftrership agreement), and would tlryically 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 complere 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) Confinn 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 ofiicer of the company named above. I am authorized to make this certification for the Study Area Code listed
above.
AKMInitial
2
Annual Recertilication
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-Decernber)
A. Subscribers eligible for recertification by anniversary monthB. Subscribers de-enrolled prior to recertification attemptsC. Total number of subscribers ETC is responsible for recertifoing (A-B)
Recertification Methods
State of federel databaseD, Subscribers recertified through ETC access to state or federal database by anniversary month
the number of subscnlbers verified access to a state or federal database.
E. Name of the data sourc{s) used to verifu consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertifr (You may also use this section to report subscriber initiated recertifications).
the number oflifeline subecribers the ETC contacted to obtain
G. Subscribers who failed to recerti$ through ETC direct outreach attempt
the number of Lifeline
3
Jan Feb Mar Apr May Jun JUI Aug sep Oct Nov Dec Year
Totrl
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 Jul Aug sep Oct Nov Dec Yerr
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 Yerr
Totel
F.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
c 0 0 0 0 0 0 0 0 0 0 0 0 0
H. Subscribers who recertified through ETC direct outreach attempt
the number ofLifeline subscribers that
Third PartyI. Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number ofLifeline subscribeis contacted a stBte adminisuator third or USAC forthe ofrecertification.
J. Name of third party administrator used to veri$ subscriber eligibility:
K. Subscribers de-enrolled as a result of a third party recertification attempt
the number ofsubscnibers as a resuh or to ouEeach from a stat€lhid or USAC.
L. Subscribers who recertified through a state administrator, thi.d party administrator, or USAC's recertification effort
the number ofsubscribers thm recertificd I ftom a state thtud oTUSAC
Certification:
Recertifi cation Methods Database
I certifu that the company listed above has procedures in place to recertiff consumer eligibility by relying on a database. I
am an offlcer of the company named above. I am authorized to make this certification for the SAC(s) listed above.
Initial
4
Jan Feb Mar APr May Jun Jul Aug sep tu Nov Dec Yeor
Total
H.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
Totel
I.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 Year
Totel
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Year
Totel
Jrn Feb Mar Apr May Jun Jul Aug sep Oct Nov Dm
L.0 0 0 0 0 0 0 0 0 0 000
Recertilication Method: ETC
I certi$ 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.
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 officer 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 current Form 555
data year. I am an ofiicer 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.
Siped,
Amanda Moore, Assistant Treasurer Amanda Moore, Assistant Treas
Sigrature of Officer
Ama nda. moore@tdstelecom. co m
Email Address of Officer
Nicole Mauritz
Person Completing This Certification Form
Printed Name and Title of Officer
Jan 31 ,2022
Date
6086642415
Contact Phone Number
11 = (c+K)yrq = @+F+I)O =M/.I\rlfi)
Total number of subscrlbers de-enrolled as
a result of recertification
Total number of subscrlbers ETC ts
responsible for recertifying
Percent of subscriberc due for
recerdfication who were de-enrolled
0 0 0.0o/o
5
Affiliated ETCs
SAC Name
100005 Cobbosseecontee Telephone Company
6
SAC Name
Attachment - TDS Telecommunications LLC Affiliates
SAC Name
100005 Cobbosseecontee Telephone Com oanv
100007 The lsland Teleohone Comoanv
100010 Hamoden Teleohone Comoanv
'100011 Hartland & St. Albans Telephone Company
100024 Somerset Teleohone Comoanv
100031 Warren Telephone Company
100034
The West Penobscot Telephone and Telegraph
Comoanv
109002 U.S. Cellular
120045 Kearsaroe Teleohone Comoanv
120047 Merrimack Countv Telephone Companv
120049 Union Telephone Company
120050 Wilton Teleohone Companv. Inc.
123321 Hollis Telephone Comoanv. lnc.
129002 NH #1 Rural Cellular. lnc. (U.S. Cellular)
140058 Ludlow Telephone Company
140061 Northfield Teleohone Comoanv
140062 Perkinsville Telephone Companv. lnc.
150089 Deoosit Teleohone Comoanv. lnc.
150092 Edwards Telephone Comoanv. lnc.
150114 Oriskanv Falls Teleohone Corooration
1501 18 Port Byron Telephone Companv
150129 Townshio Teleohone Comoanv. lnc.
150133 Vernon Telephone Company, lnc.
170183 Mahanov & Mahantanqo Teleohone Comoanv
170206 Suqar Valley Telephone Comoany
190217 Amelia Teleohone Corooration
190253 Virqinia Telephone Comoany
193029 New Castle Teleohone Co.
209005 Hardy Cellular Telephone Company (U.S. Cellular)
210338 Quincv Teleohone Comoanv (FL)
220338 Quincv Telephone Comoanv (GA)
2203/16 Blue Ridoe Teleohone Comoanv
220351 Camden Telephone and Teleqraph Company, lnc.
220375 Nelson-Ball Ground Telephone Company
239006 Wilminoton Cellular Teleohone Comoanv
240533 McClellanville Telephone Company, lnc.
240535 Nonltrav Teleohone Co. lnc
240544 St. Stephen Telephone Company
240551 Williston Teleohone Comoanv
25028/Butler Telephone Company, lnc
250311 Oakman Telephone Comoanv. lnc.
250314 Peooles Telephone Companv. lnc.
3L0677 lsland Telephone Company
310685 Chatham Teleohone Comoanv
3L0726 Shiawassee Telephone Company
310738 Wolverine Teleohone Comoanv
320744 Camden Telephone Company, lnc.
320776 Communications Corporation of lndiana
320777
The Home Telephone Company of Pittsboro,
lnc.
320778 Home Telephone Company, lnc.
320788
The Merchants and Farmers Telephone
Comoanv
320809
Communications Corporation of Southern
lndiana
320816 S & W Teleohone Comoanv. lnc.
320829 Tioton Telephone Companv. lnc.
320830 Tri-County Communications Corporation
320837 West Point Teleohone Company
330844 Badqer Telecom, LLC
330849 Black Earth Teleohone Comoanv. LLC.
330851 Bonduel Telephone Company, LLC
3308s6
Burlington, Brighton & Wheatland Telephone
Comoanv. LLC
330859 Central State Telephone Companv, LLC
33087s Dickewille Teleohone. LLC
330880 The Farmers Telephone Company, LLC
330881 Mid-Plains Teleohone. LLC
330909 Midway Telephone Company, LLC
330914 EastCoast Telecom of Wisconsin. LLC
330915 Mosinee Telehphone Company
330917 Mt. Vemon Teleohone Comoanv. LLC
330930 Grantland Telecom, LLC
330943 Rivercide Telecom. LLC
330945 Scandinavia Telephone Company, LLC
330952 Southeast Teleohone Co. of Wisconsin. LLC
3309s4
Stockbridge & Shenrood Telephone Gompany,
LLC
330955 State Lono Distance Teleohone Comoanv
3309s8 Tennev Teleohone Comoanv. LLC
330953 Utelco, LLC
330968 Waunakee Teleohone Comoanv. LLC.
339007 United States Cellular Operating Company, LLC
3s9016
Farmers Cellular Telephone Company, Inc.
(U.S. Cellular)
361350 Arviq Telephone Company
361352 Bridoe Water Teleohone Co.
351413 KMP d/b/a Mid-State Teleohone Company
351433 Mid-State Teleohone Com oanv
361507 Winsted Telephone Company
Attachment - TDS Telecommunications LLC Affiliates
260411 Leslie Countv Teleohone Comoanv
260412 Lewisoort Teleohone Co.
260417 Salem Telephone Co.
280448 Calhoun Citv Teleohone Comoanv. lnc.
28330'r Southeast Mississippi Telephone Company, lnc.
287449 Mvrtle Teleohone Comoanv. lnc.
290559 Concord Telephone Exchanqe, lnc
290566 Humphrevs County Telephone Company
290575 Tennessee Teleohone Company
290578 Tellico Telephone Company, lnc.
299010
United States Cellular Operating Company of
Knoxville
300585 Arcadia Teleohone Company
300607 Continental Telephone Company
300613 Little Miami Communications Comoration
300645 Oakwood Telephone Company
300662 The Vanlue Teleohone Companv
310672 Communications Corporation of Michigan
431984 Oklahoma Communication Systems, lnc.
4320t0 Mid-America Teleohone. lnc.
452L7L Arizona Telephone Company
452L74 Southwestern Teleohone Comoanv
462L84 Delta County Tele-Comm, lnc.
462207 Strasburq Telephone Company
472230 Potlatch Telephone Comoanv. lnc.
522404 Asotin Telephone Company (WA)
522427 Lewis River Teleohone Comoanv. lnc.
522430 McDaniel Telephone Company
529001
McDaniel CellularTelephone Company (U.S.
Cellular)
532404 Asotin Teleohone Comoanv (OR)
539002 USCOC of Oregon RSA #5, Inc. (U.S. Cellular)
542321 Haoov Vallev Teleohone Comoanv
542322 Hornitos Telephone Company
542323 Winterhaven Teleohone Comoanv