20220201Torch Wireless Form 555.pdf

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Annual Lifeline Eligible Telecommunications Carrier Certification f,'orm All carriers mu51 ssmplete all or portions
of all sections Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31't (Annually)
T- LL- O
Does the reporting company have affiliated ETCs? Yes E[ No E[
Provide a list of all ETCs that are afiliated wtth the reporting ETC, using page 4 and additional sheets if necessary. Afiliation shall be
determined in accordance with Seclion 3(2) of the Communications Act. Thot Section detines "afiliate" as "a Wrson that (directly or indirectly)
oww or conlrols, is owned or controlled by, or is wtder common ownership 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
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1
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).
202'l lD N/A
479029 143050568
State ETC Name
N/A
Recertification Year
N/A
Holding CompanyNarne
(l/sane as ETC name, list "N/A" Do not leave blank)
DBA, Marketing, or Other Branding Name
(If sane as ETC name, list "N/A" Do rct leave blank)
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 subscrtbers 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 nutnber of
subscribers 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-Usage
January 0
February 0
March 0
April 0
May 0
June 0
July 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
parbnership agreement), and would tlpically 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 Certilicatioll Atl ETCs must complete 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) 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 officer of the company named above. I am authorized to make this certification for the Study Area Code listed
above.
JEPInitial
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 recertiffinS (A-B)
Recertilication Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
of
E. Name of the data sourc{s) used to verifu consumer eligibility:
ETC Direct ContectF. Subscribers contacted by ETC directly to recerti$ (You may also use this section to report subscriber initiafed recertifications).
of Lifeline
G. Subscribers who failed to recertifr through ETC direct outreach attempt
dueto or
3
Jen Feb Mer Apr May Jun Jul 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
Jen Feb Mer Apr May Jun JUI Aug sep Oct Nov Dec Yer
Totrl
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
Totd
F 0 0 0 0000 0 0 0 0 0 0
Jan Feb Mer Apr Mey Jun Jul Aug sep Oct Nov Dec Ycer
Total
0 0G.0 0 0 0 0 0 0 0 0 0 0
H. Subscribers who recertified through ETC direct ouheach atternpt
the number of Lifeline subscribers that recertified ETC's outreach
Third Party
L Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number ofLifeline subscribers contacted I state third oTUSAC forthe of recertificatim.
I. Name of third party administrator used to veri! subscriber eligibility:
K. Subscribers de-enrolled as a result ofa thiod party recertification attempt
the number ofsubscribers as a result or to outreach ftom a state third or USAC.
L. Subscribers who recertified through a state administrator, third party adminishator, or USAC's rec€rtification effort
the number of subsoribers rhar recertified a from a state lhid administator or USAC
Certification:
Recertilication Method: Database
I certiff that the company listed above has procedures in place to recertiff 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.
IEElInitial "'
4
Jan Feb Mar Apr May Jun sep Oct Nov Dcc Yeer
Totel
Jul Aug
H.0 0 0 0 0 0 0 0 0 0 0 0 0
Jrn tr'eb 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 Oct Nov Dec Yetr
Total
K.0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb Mar Apr Mey Jun Jut Aug sep Oct Nov Dec Year
Totel
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 sigrred 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 JEP
Recertification Method: Third Party
I certiS that the company listed above has procedures in place to recertiff consumer eligibility by relying on an
administrator. I am an ofiicer 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 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 certifr 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,
JORGE E PEREA, CEO JORGE E PEREA, CEO
Signature of Officer
JPEREA@TORCHWT RELESS.C(
Email Address of Officer
JORGE PEREA
Person Corylaing This C€rtificatior Form
Printed Name and Title of Officer
Jan 31 ,2022
Date
9047204505
Contact Phone Number
5
M:(c+K)1r1 = @+F+I)O = M/N*lfi)
Total number ofsubscrlben de-errollcd es
t result of recertiflcation
Total number of subscribers ETC ls
reponsible for recerfiSing
Percent of subscriben due for
recerdflcation who were de.enrolled
0 0 O.0o/o
Affiliated ETCs
SAC Name
6