20250123Mud Lake Telephone Cooperative Assn. Inc. Form 555.pdf

RECEIVED
2025 January 23 T(509)747-2600
F(509)624-5129
MOSSADAMS IDAHO PUBLIC
UTILITIES COMMISSION 601 W.Riverside Avenue
Suite 1800
Spokane,WA 99201
VIA EMAIL: secretary(a)puc.idaho.gov
January 23, 2025
Idaho Public Utilities Commission
Monica Barrios-Sanchez
Commission Secretary
11331 W. Chinden Blvd., Bldg. 8
Suite 201-A
Boise, ID 83720-0070
Re: Case No. GNR-T-25-01 In the Matter of the 2025 Lifeline- FCC Form 555 Filing
Dear Ms. Barrios-Sanchez:
Attached for filing in accordance with the above referenced proceeding is a copy of the Form 555 for
Mud Lake Telephone Cooperative Assn Inc. (SAC 472227).
An electronic version of the filing was also submitted via the FCC's website on January 22, 2025.
If you have any questions or concerns about this Certification, please contact me.
Sincerely,
Tym Rutkowski
Managing Director
[phone]
tym.rutkowski(a-�mossadams.com
Attachment
Assurance,tax,and consulting offered through Moss Adams LLP.Wealth management offered through Moss Adams Wealth Advisors LLC.Investment banking offered through Moss Adams Capital LLC.

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)
472227 143002519
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).
2024 ID Mud Lake Telephone Cooperative Assn., Inc.
Recertification Year State ETC Name
DBA, Marketing,or Other Branding Name Holding Company Name
(If same as ETC name,list WIA"Do not leave blank) (If same as ETC name,list WIA"Do not leave blank)
Does the reporting company have affiliated ETCs? Yes_ No X
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 orcontrol 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
1

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.
1 am an officer of the company named above. I am authorized to make this certification for the SAC listed
above.
Initial RM
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 RM
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_ No X
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
February
March
April
May
June
July
August
September
October
November
December
Total Subscribers 0
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,
Randy Mead Randy Mead-General Manager
Signature of Officer Printed Name and Title of Officer
[e-mail] 01-22-2025
Email Address of Officer Date
Samantha Simatos 5097770209
Person Completing This Certification Form Contact Phone Number
3