20230201Cable One VOIP Form 555.pdf

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TN
Cable One
JENAT HECI(
ASSISTANT GENERAL COUNSEt
210 E. Earll Drive
Phoenix, Ari?ona 85012
PH:507-364-5092
FAX: [phone]
[e-mail]
January 31,2023
Jan Noriyuki
Commission Secretary
ldaho Public Utilities Commission
1'1331 W Chinden Blvd.
Building B, Suite 241-A
Boise, lD 83714
secrelary@ouc. idaho.oov
Re: Cable One VolP LLC; Copy of Form 555 for State of ldaho (2022 Data Certification)
sAC - 479030
Dear Jan Noriyuki:
As required by Federal Communications Commission (FCC) Regulations, Cable One VolP LLC is submitting a
copy of its Annual Lifeline Eligible Telecommunications Carrier Certification Form (FCC Form 555) for the State
of ldaho. This Form was recently filed by Cable One VolP LLC with the FCC in the FCC's Electronic Comment
Filing System, Docket 14-171.
lf you have any questions, please contact me via emailat [e-mail].
$incerely,
H,rk-
Heck
Enclosure
JH:jlc
RECEIVED
2023 January 31, 3:11PM
IDAHO PUBLIC
UTILITIES COMMISSION
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 CommissionIMPORTANT: 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).
State ETC Name
DBA, Marketing, or Other Branding Name Holding Company Name
(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?Yes No
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
Cable One, Inc.
ID
143016933
Cable One VoIP, LLC
Recertification Year
Sparklight
2022
479030
279065 Cable One VoIP, LLC
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 subjectto the non-usage requirements. ETCs subject to the non-usage requirements must indicate the number of subscribers de-enrolled by month inSection 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 ofsubscribers de-enrolled by month.
Is the ETC sub ect to the non-usa e re uirements?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.
0
0
0
0
0
Initial _________
0
0
0
0
0
0
0
0
QAT
Annual Recertification
Do not leave empty blocks. If an 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 month
B. Subscribers de-enrolled prior to recertification attempts
C. 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
H. Subscribers who recertified through ETC direct outreach attempt
Report the number of Lifeline subscribers that successfully recertifiedthrough 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
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
Si nature 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,
Signature of Officer
Person Completing This Certification Form
Printed Name and Title of Officer
Date
Contact Phone Number
0 0
Jan 31, 2023
Quynh Tran
Email Address of Officer
Jenae Heck
0.0%
602-364-6092
[e-mail]
/s/ Quynh Tran, Vice President & Treasurer
QAT
Affiliated ETCs
SAC Name
Fidelity Telephone LLC421882
439048 Fidelit Cablevision LLC
429002 Fidelity Cablevision LLC
240523 Hargray Telephone Co. Inc.
240512
220369
Bluffton Telephone Co.
ComSouth Telecommunications