20220203Assurance Wireless 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
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31* (Annually)
Does the reporting company have afliliated ETCs? Yes E[ No E[
Provide a list of all ETCs that are afiliated with the reporting ETC, using page 4 and additional sheets if necessary. Afiliation shall be
determined in accordance with Section 3(2) of the Communications Act. That Section dertnes "afiliate " as "a person that (directly or indirectly)
owns 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.R. $ 76.1200.
Affiliated ETC's SAC Affiliated ETC's Name
.iaho Public Utilities Commission
Office of the SecretaryBECEIVED
!:rR 0 3 2022
Boise, ldaho
479015 143033426
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier (ETC) must provide a certificationformfor each SAC through which it provides Lifeline service).
2021 lD Assurance Wireless USA L.P.
Recertification Year
Assurance Wireless
State ETC Name
T-Mobile USA, lnc.
DBA, Marketing, or Other Branding Name
(lf same as ETC name, list "N/A" Do yllene blank)
Holding CompanyName
(lf same as ETC name, list "N/A" Do rct leave blank)
1
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 subscribers 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 that only assess a fee but do not collect such fees are subject to the non-usage requirements and tnust 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 subscibers 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 796
June 155
July 147
August 122
September 116
October 27
Novernber 125
December 100
Total Subscribers 1588
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 by-laws (or
parhrership 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 Certificatioa. Ail ETCs must complete this section
I certifu that the company listed above has certification procedures in place to:
A) Review income and program-based eligibility documentation prior to enrolling a consurner 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.
LWInitial
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-December)
A. Subscribers eligible for recertification by anniversary monthB. Subscribers de-enrolled prior to rccertification attemptsC. Total number of subscribers ETC is responsible for recertifring (A-B)
Recertification Methods
State of federal databaseD. Subscribers recertified through ETC access to state or federal database by anniversary month
number of or federal database.
E. Name of the data sourc{s) used to verifo consumer eligibility:
ETC Direct ContactF. Subscribers contacted by ETC directly to recertiff (You may also use this section to report subscriber initiated recertifications).
of ETC contacted
G. Subscribers who failed to recertifr through ETC direct ouheach attempt
of Lifeline outreach
3
Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec Year
Totel
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 Year
Totel
D,0 0 0 0 0 0 0 0 0 00 0 0
Jen Feb Mer Apr May Jun JUI Aug sep Oct Nov Dec Year
Total
F 0 0 0 0 0 0 o 0 0 0 0 0 0
Jen Feb Mrr Apr May Jun Jul Aug sep Oct Nov Dec Year
Total
0 0G.0 0 0 0 0 0 0 0 0 0 0
H. Subscribers who recertified through ETC direct ouhach attempt
the number of Lifeline subscribers that recertified ETC's
Third Party
I. Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
the number of Lifeline subscribets contact€d a state third or USAC for the 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 or to ou8each fiom a state adminisra,tor ftird
L. Subscribers who recertified through a state administrator, third party administrator, or USAC's recedification effort
the number ofsubscribers that recertified from a state ftird or USAC
or USAC.
a
Certilication:
Recertification Method: Datsbase
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.
Initial
4
Jan 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
Jan Feb Mer Apr May Jun JUI Aug seP Oct Nov Dec Year
Total
0I.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
Totel
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 Yeer
Total
L,0 0 0 0 0 0 0 0 0 0 0 0 0
Recertilication Method: ETC
I certiff 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 oflicer of the company named above. I am authorized to make this
certification for the SAC(s) listed above.
Initial
Recertification Method: Third Party
I certi$ that the company listed above has procedures in place to recertiff consumer eligibility by relying on an
adminisffator. 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 certift that my company did not claim federal low income support for any Lifeline subscribers for the current Fonn 555
data year. I am an offrcer of the company named above. I am authorized to make this certification for the SAC listed
above.
Initial
Signature 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.
Signed,
Larry Weians, Vice President Larry Weians, Vice President
Sigrature of Oflicer
[e-mail]
Email Address of Officer
Kaitlyn Hill
Person Coryleting This Certification Form
Printod Name and Title of Officer
Jan 31 2022
Date
9132260883
Contact Phone Number
5
M:(c+K)1ri = @+F+I)O = M/Ntlfi)
Total number of subscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recerdfying
Percent ofsubscdbers due for
recertiffcation who were de-enrolled
0 0 0.0%
Affiliated ETCs
SAC Name
179014 T-Mobile USA lnc.
199016 T-Mobile USA lnc.
219013 T-Mobile USA lnc.
269024 T-Mobile USA lnc.
289029 T-Mobile USA lnc.
369014 T-Mobile USA lnc.
529013 T-Mobile USA lnc.
639003 T-Mobile Puerto Rico LLC
109010 Assurance Wireless USA L.P
1 19003 Assurance Wireless USA L.P
129005 Assurance Wireless USA L.P
139003 Assurance Wireless USA L.P
159018 Assurance Wireless USA L.P
169003 Assurance Wireless USA L.P
179012 Assurance Wireless USA L.P,
189009 Assurance Wireless USA L.P
1 9901 3 Assurance Wireless USA L.P
209015 Assurance Wireless USA L.P
219012 Assurance Wireless USA L.P
229015 Assurance Wireless USA L.P
239018 Assurance Wireless USA L.P
249013 Assurance Wireless USA L.P
259032 Assurance Wireless USA L.P
269027 Assurance Wireless USA L.P
27903/.Assurance Wireless USA L.P
289028 Assurance Wireless USA L.P
299018 Assurance Wireless USA L.P
309005 Assurance Wireless USA L.P
319023 Assurance Wireless USA L.P
329011 Assurance Wireless USA L.P
339032 Assurance Wireless USA L.P.
349033 Assurance Wireless USA L.P
359126 Assurance Wireless USA L.P
369018 Assurance Wireless USA L.P
409025 Assurance Wireless USA L.P
419024 Assurance Wireless USA L.P
429025 Assurance Wireless USA L.P
449061 Assurance Wireless USA L.P
459018 Assurance Wireless USA L.P
469014 Assurance Wireless USA L.P
499015 Assurance Wireless USA L.P
509006 Assurance Wireless USA L.P
529014 Assurance Wireless USA L.P
53901 1 Assurance Wireless USA L.P
s49016 Assurance Wireless USA L.P
559021 Assurance Wireless USA L.P
569003 Assurance Wireless USA L.P
579003 Assurance Wireless USA L.P
589006 Assurance Wireless USA L.P
5