20230131Assurance Wireless Form 555.pdf

1
Annual Lifeline Eligible Telecommunications Carrier Certification 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 31st (Annually)
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier (ETC) must provide a certification form for each SAC through which it provides Lifeline service).
(If same as ETC name, list “N/A” Do not leave blank) (If same as ETC name, list “N/A” Do not leave blank)
Does the reporting company have affiliated ETCs?
Provide a list of all ETCs that are affiliated with the reporting ETC, using page 4 and additional sheets if necessary. Affiliation shall be
determined in accordance with Section 3(2) of the Communications Act. That Section defines “affiliate” 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. § 153(2). See also 47
C.F.R. § 76.1200.
Affiliated ETC’s SAC Affiliated ETC’s Name
T-Mobile USA, Inc.
ID
143033426
Assurance Wireless USA L.P.
Assurance Wireless
2022
479015
RECEIVED
2023 January 30, 4:14PM
IDAHO PUBLIC
UTILITIES COMMISSION
2
ETCs Subject to the Non-Usage Requirements
All ETCs must complete the appropriate check-box. ETCs that do not assess and collect a monthly fee from 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 must also indicate the number of subscribers de-enrolled by month.
Is the ETC subject to the non-usage requirements? Yes No
If yes, record the number of subscribers de-enrolled for non-usage by month in Block Q below.
P Q
Month Subscribers De-Enrolled for Non-Usage
January
February
March
April
May
June
July
August
September
October
November
December
Total Subscribers
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
partnership 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 Certification All ETCs must complete this section
I certify 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.
Initial _________
243
290
440
240
284
LW
354
328
666
227
310
294
4076
400
3
Annual Recertification
Do not leave empty blocks. If an ETC has nothing to report in a block, en ter a zero.
Report the number of Lifeline subscribers due for recertification by month (January-December)
A.Subscribers eligible for recertification by anniversary month
B.Subscribers de-enrolled prior to recertification attemptsC.Total number of subscribers ETC is responsible for recertifying (A-B)
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year Total
A.
B.
C.
Recertification Methods
State of federal database
D.Subscribers recertified through ETC access to state or federal database by anniversary month
Report the number of eligible subscribers verified through access to a state or federal database.
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year Total D.
E.Name of the data source(s) used to verify consumer eligibility:
__________________________________________________________________
ETC Direct Contact
F.Subscribers contacted by ETC directly to recertify (You may also use this section to report subscriber initiated recertifications).
Report the number of Lifeline subscribers the ETC contacted directly to obtain recertification of eligibility
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total F.
G.Subscribers who failed to recertify through ETC direct outreach attempt
Report the number of Lifeline subscribers de-enrolled due to ineligibility or non-response to the ETC’s outreach attempt.
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year
Total G.
0
0
0 00
0
0
0
0
0
00
0 0
0
0
0
0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
0
0
0
0
0
0 0
0
0
0
0
0
0
0
0
0
0
0 0
0
0
0
00
0
0
0
0
0
0
0
0
4
H.Subscribers who recertified through ETC direct outreach attempt
Report the number of Lifeline subscribers that successfully recertified through ETC’s outreach attempt.
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year Total H.
Third Party
I.Subscribers whose eligibility was reviewed by state administrator, third party administrator, or USAC
Report the number of Lifeline subscribers contacted by a state administrator, third party administrator, or USAC for the purpose of recertification.
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year Total I.
J.Name of third party administrator used to verify subscriber eligibility:
____________________________________________________________
K.Subscribers de-enrolled as a result of a third party recertification attempt
Report the number of subscribers as a result of ineligibility or non-response to outreach from a state administrator, third party administrator, or USAC.
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year Total
K.
L.Subscribers who recertified through a state administrator, third party administrator, or USAC’s recertification effort
Report the number of subscribers that recertified through a request from a state administrator, third party administrator, or USAC
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year Total
L.
Certification:
Recertification Method: Database I certify that the company listed above has procedures in place to recertify 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 _________
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
0
0 0
0 0
0
0
0
0
0
0
00
0
0
0
00 0
0
0
0
0
0
0
0 0
0
5
Recertification Method: ETC I certify that the company listed above has procedures in place to recertify 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 officer of the company named above. I am authorized to make this
certification for the SAC(s) listed above.
Initial _________
Recertification Method: Third Party I certify that the company listed above has procedures in place to recertify 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 certify 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 _________
M = (G+K) N = (D+F+I) O = M/N*100
Total number of subscribers de-enrolled as
a result of recertification
Total number of subscribers ETC is
responsible for recertifying
Percent of subscribers due for
recertification who were de-enrolled

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,
Signature of Officer
Email Address of Officer
Person Completing This Certification Form
Printed Name and Title of Officer
Date
Contact Phone Number
Larry Weians, Vice President
0 0
Jan 27, 2023
Larry Weians, Vice President
Lyndsey Mitchell
0.0%
19132260883
[e-mail]
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Affiliated ETCs
SAC Name
Assurance Wireless USA L.P.109010
119003
129005
139003
159018
169003
T-Mobile Puerto Rico LLC
179012
189009
199013
209015
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
559021
569003
579003
589006
639003
369018
409025
419024
429025
449061
459018
469014
499015
509006
529014
549016
259032
269027
279034
289028
299018
309005
319023
329011
339032
349033
359126
219012
229015
239018
249013
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.
Assurance Wireless USA L.P.