20220207Direct Communications-Rockland Form 555.pdf

Annud llfG[rc EltsDb Tdconuudcrdonr Crrrer Ccrlt0cdon Form All cuic M ooryldo all oportior
of all eectimr Fuu mct be suffibd b USAC ud filcd u,i6 fto Fcdral Comicrtioos Comirdon
IMPORTANTS PLEASE READ INSTRUCTIONS flRST
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Fc Erposcs 6f1frfu f,lin& m oficcr is m ocqryd of a positim listod in tbc rticle of hcapuation, miclcs of fomation,
or oiltcr 8inilsr lcgd docmlot An officor ir a pamn who ocmryies a pocitim spcsificd in thc corporaE by-lawr (or
parm*ip agrec@!ot), ad would tJrplcally bo Drcsid€ofi, vice prcsidm ftr opcmtioE vice pcridcm br fnaoco,
corytollcr, teanucr, c a co,qrablc positim. If thc flcr ir a solo propriaorrhip, thc owncr mnt rigp ths ccrtificatiou
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Iccdi&6at6E coryony lised abot ehr ccrtificatimprocafurcs inphco to:
A)Rcvicwincmc odprcgrrn-bosedcligibilitydocuncmttimpricomollingaconnrmcrinthcLifolinoprcgru, and
th"t, to &o bcet of my Lnorvlodge, tho corymy war prcrdod with docunoobtim of oacb connrmer's houcehold
inconc sd/c pogrm{arcd eligbilitypric o his c hcr @ollmGot in llfollne; d/or
B) Confirm cmnmcr oligibility by rolyiag rrym apaors b a atcb d&berc and/c nodco of eligibility tom thc gtde
Lifdine sdnini!ffior pic o corolling a omsmcr in the Liftlinc progran
I am m oficc of thc coryouy uroed abovr. I am aulhorircd to mrlo this cstificatim fu tro Strdy Area Codc Usbd
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I ccilify6dtbc cqmylirudabovo huproocrtrcs inplaoc oroccrtif cunrncrdigibilitybyrolyiago a databue. Iu an offcor of the corymy nd $orrc. I am arthsizd to nrkc this ocrtificCio fo eo SAC(e) listcd above.
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I ceti$ that tho oomgauy lirted abovp has prcccdur€s in placc to rtccrti& tbs cdinuod oligibility of dl of ib tiftlim
st$scribcr$ edlh!t,tott;bectofmytnonlodgo, thccoryauyobrtainodrigncdcstificatimrfionall arbcdbcses6ng
to tbir eligibility for Lifolinc. I am an officor of &o coryuy nrrn€d abovE I am arthuird to nr&o 6is
certification for 6e SAC{a) lirted above.
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listcd abovs.
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I ceci$ that uy coryany did lot ddm fcdrsl bw incms $ryport for auy Li&linc rubccribcrs fu the curom Fcn 555
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