Annual Lifeline Certification & Verification Letter

Approved by OMB

   3060-0819

Annual Lifeline Certification & Verification

Complete Section 1, 2, 3, or 4. Then complete the chart below.

1. Eligible Telecommunications Carrier (ETC) serving Federal Default State (complete columns A through F and sign below)

I certify that the company listed below has procedures in place to verify the continued eligibility of a statistically valid random sample of its Lifeline customers. Results are provided in the chart below. I certify that the company listed below has procedures in place to review income documentation and that, to the best of my knowledge, the company was presented with documentation of the consumer’s household income. I am an officer of the company named below. I am authorized to make this certification for the Study Area(s) listed below.

OR

2. Eligible Telecommunications Carrier (ETC) serving Non-Federal Default State (complete columns A through C and sign below; complete columns D and E if required by your state commission)

I certify that the company listed below is in compliance with the Lifeline and Link Up verification procedures in place in the state(s) listed below. If any Lifeline customers of the company listed below qualify based on income, I certify that the company listed below is in compliance with state Lifeline income certification procedures and that, to the best of my knowledge, documentation of income was presented. I am an officer of the company named below. I am authorized to make this certification for the Study Area(s) listed below.

OR

3. Wireless Eligible Telecommunications Carrier (ETC) serving Non-Federal Default State that does not assert jurisdiction over Wireless ETCs, and, therefore, is following federal default certification and verification procedures (complete columns A through F and sign below)

I certify that the company listed below has procedures in place to verify the continued eligibility of a statistically valid random sample of its Lifeline customers. Results are provided in the chart below. I certify that the company listed below has procedures in place to review income documentation and that, to the best of my knowledge, the company was presented with documentation of the consumer’s household income. I am an officer of the company named below. I am authorized to make this certification for the Study Area(s) listed below.

OR

4. I certify that my company has not claimed federal Low Income support for any Lifeline customers in _____ (insert current year).

A	B	C	D	E	F
Company Name*	SAC (6 digit number)	State	CustomersSurveyed or Verified	Customers Found to be Ineligible	Non-Responding Customers
     	     		     	     	     
     	     		     	     	     
     	     		     	     	     
     	     		     	     	     
     	     		     	     	     

* Companies with more than 5 SACs in any of the categories enumerated as 1-4 above may attach an Appendix with the requested information for the chart.

Signed,

     

(Signature of Officer)

     

(Printed Name of Officer)

     

(Title of Officer)

     

(Person Completing this Sample Letter)

     

(Contact Phone Number)

     

     

(Company Address)

     

(Date)

Submit to USAC using only ONE method:

Fax to: (202) 776-0080

E-mail to: [email protected]

Mail to: USAC - Low Income Program

2000 L Street, NW, Suite 200

Washington, DC 20036

Deadline: August 31^st

This document contains proposed modified information collection requirements. The Commission, as part of its continuing effort to reduce paperwork burdens, invites the general public and the Office of Management and Budget (OMB) to comment on the information collection requirements contained in this document, as required by the Paperwork Reduction Act of 1995, Public Law 104-13. In addition, pursuant to the Small Business Paperwork Relief Act of 2002, Public Law 107-198, see 44 U.S.C. 3506(c)(4), we seek specific comment on how we might further reduce the information collection burden for small business concerns with fewer than 25 employees."

August 2011