FCC Form 555 FCC Form 555

Revisions Pending OMB Approval

3060-0819

FCC Form 555

[MONTH] 2015

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 31^st (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

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.

Section 1: Initial Certification All ETCs must complete this section

I certify that the company listed above has certification procedures in place to:

1. 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

2. 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

Section 2: Annual Recertification

Do not leave empty blocks. If an ETC has nothing to report in a block, enter a zero.

A	B	C	D	E = (A – B – C – D)
Number of subscribers claimed on February FCC Form 497 of current Form 555 calendar year (February data month)	Number of lines claimed on February FCC Form 497 of current Form 555 calendar year provided to wireline resellers	Number of subscribers claimed on the February FCC Form 497 that were initially enrolled in the current Form 555 calendar year (These subscribers did not have Lifeline service prior to January 1 of the current 555 calendar year.)	Number of subscribers de-enrolled prior to recertification attempt by either the ETC, a state administrator, access to an eligibility database, or by USAC	Number of subscribers ETC is responsible for recertifying for current Form 555 calendar year

Recertification Results:

F	G	H = (F-G)	I	J = (H+I)
Number of subscribers ETC contacted directly to recertify eligibility through attestation	Number of subscribers responding to ETC contact	Number of non- responding subscribers	Number of subscribers responding that they are no longer eligible (This should be a subset of Block G.)	Number of subscribers de- enrolled or scheduled to be de-enrolled as a result of non-response or response of ineligibility from ETC recertification attempt

K	L
Number of subscribers whose eligibility was reviewed by state administrator, ETC access to eligibility database, or by USAC	Number of subscribers de-enrolled or scheduled to be de-enrolled as a result of finding of ineligibility by state administrator, ETC access to eligibility database, or USAC

Note: If any subscriber was reviewed by an ETC accessing a state database or by a state administrator and subsequently contacted directly by the ETC in an attempt to recertify eligibility, those subscribers should be listed in Blocks F through J as appropriate and not in Blocks K and L. As a result, all subscribers subject to recertification who were not de-enrolled prior to the recertification attempt must be accounted for in Block F or Block K.

The total of Block F and Block K should equal the number reported in Block E.

Certification:

Based on the data entered above, initial the certification(s) below that apply. Both Certification A and B may apply depending on the recertification procedures in place for the SAC reporting on this form. If Certification C applies, neither Certification A nor B may apply.

A.) 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. Results are provided in the chart above in Blocks F through J. I am an officer of the company named above. I am authorized to make this certification for the SAC listed above.

Initial

AND/OR

B.) I certify that the company listed above has procedures in place to recertify consumer eligibility by relying on:

(List database or name of administrator here) . Results are provided in the chart above in Blocks K through L. I am an officer of the company named above. I am authorized to make this certification for the

SAC listed above.

Initial

OR

C.) I certify that my company did not claim federal low income support for any Lifeline subscribers for the February

Form 497 data month for the current Form 555 calendar year. I am an officer of the company named above. I am authorized to make this certification for the SAC listed above.

Initial

Section 3: De-enroll Percentage

Using the data entered in Section 2, complete the chart below to find the percentage of subscribers de-enrolled for this ETC.

M = (F+K)	N = (J+L)	O = ((N ÷ M) * 100)
Number of subscribers that the ETC attempted to recertify directly or through a state administrator, ETC access to a state database, or by USAC (This should equal the number reported in Block E)	Number of subscribers de- enrolled or scheduled to be de- enrolled as a result of non-response or ineligibility	Percentage of subscribers de-enrolled or scheduled to be de-enrolled as a result of ineligibility or non-response

Section 4: 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

Signature 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 Printed Name and Title of Officer

Email Address of Officer Date

Person Completing This Certification Form Contact Phone Number

Affiliated ETCs

SAC	Name

3