20240130Assurance Wireless Form 555.pdf

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)
479015 143033426
Study Area Code (SAC)Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carrier (ETC) must provide a certification form for each SAC that provides Lifeline service).
2023 ID Assurance Wireless USA, L.P.
Recertification Year State ETC Name
Assurance Wireless T-Mobile USA, Inc.
DBA, Marketing, or Other Branding Name
(If same as ETC name, list “N/A” Do not leave blank)
Holding Company Name
(If same as ETC name, list “N/A” Do not leave blank)
Does the reporting company have affiliated ETCs? Yes X 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
639003 T-Mobile Puerto Rico LLC
299018 Assurance Wireless USA, L.P.
239018 Assurance Wireless USA, L.P.
199013 Assurance Wireless USA, L.P.
159018 Assurance Wireless USA, L.P.
319023 Assurance Wireless USA, L.P.
449061 Assurance Wireless USA, L.P.
189009 Assurance Wireless USA, L.P.
279034 Assurance Wireless USA, L.P.
219012 Assurance Wireless USA, L.P.
169003 Assurance Wireless USA, L.P.
209015 Assurance Wireless USA, L.P.
289028 Assurance Wireless USA, L.P.
329011 Assurance Wireless USA, L.P.
259032 Assurance Wireless USA, L.P.
139003 Assurance Wireless USA, L.P.
129005 Assurance Wireless USA, L.P.
569003 Assurance Wireless USA, L.P.
579003 Assurance Wireless USA, L.P.
529014 Assurance Wireless USA, L.P.
359126 Assurance Wireless USA, L.P.
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RECEIVED
Tuesday, January 30, 2024 5:31PM
IDAHO PUBLIC
UTILITIES COMMISSION
249013 Assurance Wireless USA, L.P.
179012 Assurance Wireless USA, L.P.
229015 Assurance Wireless USA, L.P.
409025 Assurance Wireless USA, L.P.
309005 Assurance Wireless USA, L.P.
269027 Assurance Wireless USA, L.P.
109010 Assurance Wireless USA, L.P.
119003 Assurance Wireless USA, L.P.
589006 Assurance Wireless USA, L.P.
509006 Assurance Wireless USA, L.P.
419024 Assurance Wireless USA, L.P.
339032 Assurance Wireless USA, L.P.
469014 Assurance Wireless USA, L.P.
499015 Assurance Wireless USA, L.P.
369018 Assurance Wireless USA, L.P.
429025 Assurance Wireless USA, L.P.
459018 Assurance Wireless USA, L.P.
549016 Assurance Wireless USA, L.P.
559021 Assurance Wireless USA, L.P.
349033 Assurance Wireless USA, L.P.
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Initial Certification All ETCs must complete this section.
I certify that the company listed above:
•Has policies and procedures in place to ensure that its Lifeline subscribers are eligible to receive Lifeline
services; and
•Is in compliance with all federal Lifeline certification procedures; and
•Is in compliance with the minimum service levels set forth in 47 C.F.R. § 54.408.
I am an officer of the company named above. I am authorized to make this certification for the SAC listed
above.
Initial LW
Annual Recertification Results
Report the results of recertification efforts for the current calendar year.
Do not leave blocks empty. If the National Verifier is responsible for conducting recertification, enter zero for blocks A - F. If the state Lifeline
Administrator is responsible for conducting recertification, report the results for each block.

A. Subscribers eligible for recertification within current calendar year
B. Subscribers de-enrolled prior to recertification attempts
C. Total number of subscribers required to be recertified (A-B)
D. Subscribers successfully recertified
E. Subscribers de-enrolled for failed recertification
F. Percentage de-enrolled for failed recertification (E/C)
I certify that the company listed above has procedures in place to recertify consumer eligibility by relying upon
notice of eligibility from: state Lifeline administrator X National Verifier
I am an officer of the company named above. I am authorized to make this certification for the SAC listed
above.
Initial LW
No Subscribers Certification Complete this section if ETC claimed no Lifeline subscribers.
I certify that my company did not claim federal low income support 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(s) listed on this form
Initial
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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. 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 X No
If yes, record the number of subscribers de-enrolled for non-usage by month in Block H below.

G H
Month Subscribers De-Enrolled for Non-Usage
January 62
February 58
March 79
April 68
May 85
June 82
July 77
August 110
September 109
October 112
November 102
December 86
Total Subscribers 1030
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.
Signature Block
By signing below, I certify that the information provided is true and accurate. I am an officer of the company named
above. I am authorized to make this certification for this SAC.

Signed,

Larry Weians Larry Weians - Vice President
Signature of Officer Printed Name and Title of Officer
[e-mail] 01-25-2024
Email Address of Officer Date
Lyndsey Mitchell [phone]
Person Completing This Certification Form Contact Phone Number
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