Form FCC Form 555 FCC Form 555 Annual Lifeline Eligibility Telecommunications Carrier C

Approved by OMB

3060-0819

FCC Form 555

November 2012

Annual Lifeline Eligible Telecommunications Carrier Certification Form

All carriers must complete Sections 1, 2, and 3. Carriers must complete Section 4, if applicable.

Deadline: January 31^st(Annually)

State (An Eligible Telecommunications Carrier (ETC) must provide a certification form for each state in which it provides Lifeline service).
Study Area Code(s) (SAC)			ETC Name(s)
Holding Company Name(s)			DBA, Marketing or Other Branding Name(s)
Affiliated ETCs (include names and SACs, attach additional sheets if necessary)

Section 1: All ETCs (Initial the certification that applies to your ETC. Depending on the state, both certifications may apply).

I certify that the company listed above has certification procedures in place to review income and program-based eligibility documentation prior to enrolling a customer 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. I am an officer of the company named above. I am authorized to make this certification for the Study Area(s) listed above. Initial _____

(List the specific SAC(s) for which you are making this certification if it is not applicable to all of your study areas within the state. Attach additional sheets if necessary).

AND/OR

I certify that the company listed above confirms consumer eligibility by relying on _______________________ prior to enrolling a customer in the Lifeline program. (Please list the program eligibility data sources, such as ETC access to a state database and/or notice of eligibility from the state Lifeline administrator and indicate for which qualifying programs (e.g., SNAP, SSI) these sources are used to verify consumer eligibility). I am an officer of the company named above. I am authorized to make this certification for the Study Area(s) listed above. Initial _____

(List the specific SAC(s) for which you are making this certification if it is not applicable to all of your study areas within the state. Attach additional sheets if necessary).

Section 2: All ETCs(Initial the certification that applies to your ETC, and if applicable, complete columns A through L the tables below. Attach additional sheets if necessary).

A	B
Number of Subscribers Claimed on May FCC Form(s) 497	Number of Lines Claimed on May FCC Form(s) 497 Provided to Wireline Resellers
     	     

I certify that the company listed above has procedures in place to re-certify the continued eligibility of all of its Lifeline customers, and that, to the best of my knowledge, the company obtained signed certifications from all consumers attesting to their continuing eligibility for Lifeline, except those subscribers whose eligibility was verified by the company through the use of other sources of eligibility information as well as those subscribers who were re-certified by the state Lifeline administrator. Results are provided in the chart below. I am an officer of the company named above. I am authorized to make this certification for the Study Area(s) listed above. Initial _____

C	D	E =C-D	F	G = (E+F)	H
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	Number of Subscribers De-Enrolled or Scheduled to be De-Enrolled as a Result of Non-Response or Ineligibility	Number of Subscribers Who De-Enrolled Prior to Recertification Attempt
     	     	     	     	     	     

I	J	K	L
Number of Subscribers Whose Eligibility was Reviewed By State Administrator or By ETC Access to Eligibility Data	Number of Subscribers Whose Eligibility Was Examined by State Administrator or By ETC Access to Eligibility Data and Found to be Ineligible	Number of Customers De-enrolled or Scheduled to be De-Enrolled as a Result of a Finding of Ineligibility	Number of Subscribers Who De-Enrolled Prior to Recertification Attempt
     	     	     	     

OR

I certify that my company did not claim federal Low Income support for any Lifeline customers prior to June ___ (insert current year). I am an officer of the company named above. I am authorized to make this certification for the Study Area(s) listed above. Initial _____

(List the specific SAC(s) for which you are making this certification if it is not applicable to all of your study areas within the state. Attach additional sheets if necessary).

Section 3: All ETCs (Initial the certification 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(s) listed above. Initial _____

Section 4: Non-Usage Applicable to Certain Pre-Paid ETCs (the ETC does not assess or collect a monthly fee from its Lifeline subscribers)(Record the number of subscribers de-enrolled for non-usage by month in column N below).

M	N
Month	Subscribers De-Enrolled for Non-Usage
January	     
February	     
March	     
April	     
May	     
June	     
July	     
August	     
September	     
October	     
November	     
December	     

Signed,
Signature of Officer		Printed Name of Officer
Title of Officer		Date
Person Completing this Certification Form		Contact Phone Number

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, DC20036

Filing Instructions: Submit to USAC via one of the methods below.

1. Submit electronically via USAC’s E-File portal. Instructions are available at www.usac.org.

2. Fax to (202) 776-0080.

3. E-mail to [email protected].

4. Mail to USAC – Low Income Program, 2000 L Street, NW, Suite 200, Washington, DC20036.

Information Fields:

State

Enter the state for which the eligible telecommunications carrier (ETC) is filing this certification.

An ETC must provide a certification form for each state in which it provides Lifeline service.

Use a separate Annual Lifeline Eligible Telecommunications Carrier Certification Form for each

state.

Study Area Code(s) SAC

Enter the five-digit study area code (SAC), or codes, for the state for which the certification is filed. An ETC may include multiple SACs on one form only if the ETC has more than one SAC in the state indicated.

ETC Name(s)

Enter the corporate name of the ETC submitting the Annual Lifeline Eligible Telecommunications Carrier Certification Form.

Holding Company Name(s)

Enter the corporate name of the holding company of the ETC.

DBA, Marking or Other Branding Name(s)

Enter all additional names under which the ETC does business, including d/b/a’s (doing business as) and the names under which the ETC markets or brands its Lifeline service in the state reported on this Form.

Affiliated ETCs

Provide a list of all ETCs that are affiliated with the reporting ETC. 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. Use additional sheets if necessary.

Section 1:

Section 1 of the Annual Lifeline Eligible Telecommunications Carrier Certification Form requires an officer of an ETC to certify that the ETC verifies consumer eligibility prior to enrolling a consumer in Lifeline, and the method used to complete this verification. 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

All ETCs must complete Section 1 for each state in which they provide Lifeline service. An officer of the ETC must initial one or both of the certifications.

An officer of the ETC must initial the first certification in Section 1 if the ETC verifies consumer eligibility by reviewing documentation provided by the consumer. The SAC or SACs for which this certification is made must be listed. List multiple SACs only if the ETC has more than one SAC in the state for which the certification is made. Complete additional Annual Lifeline Eligible Telecommunications Carrier Certification Forms for SACs in other states.

An officer of the ETC must initial the second certification in Section 1 if the ETC verifies consumer eligibility by relying on information provided by a database or state Lifeline administrator. In the blank, provide the data source or sources used to verify consumer eligibility. Data sources can include, for example, the name of a state or federal database an ETC queried to confirm consumer eligibility or a state Lifeline administrator that provided notice of consumer eligibility to the ETC. ETCs must also indicate for which qualifying programs (e.g., SNAP, SSI) each source was used to verify consumer eligibility. The SAC or SACs for which this certification is made must be listed. List multiple SACs only if the ETC has more than one SAC in the state for which the certification is made. Complete additional Annual Lifeline Eligible Telecommunications Carrier Certification Forms for SACs in other states.

An officer of an ETC that uses multiple methods of confirming consumer eligibility should complete both certifications in Section 1, as appropriate. For example, an ETC that uses a state database to verify eligibility of consumers who qualify because they receive benefits under the SNAP program, but reviews documentation of eligibility provided by consumers who qualify under other programs or based on their income, should complete both certifications in Section 1.

Section 2:

Section 2 requires an officer of an ETC to certify either 1) that the ETC has procedures in place to re-certify the continued eligibility of its Lifeline customers, and that the ETC has copies of signed certifications, except for those instances in which re-certification of eligibility was completed by consulting a database or for those customers who were re-certified by a Lifeline administrator; or 2) that the ETC did not claim federal Low Income support for any Lifeline customers prior to June (i.e., the ETC did not file FCC Form 497 for the May data month or earlier data months in the year).

All ETCs must complete Section 2 for each state in which they provide Lifeline service. An officer of the ETC must initial one of the certifications.

An ETC must report the results of its re-certification process in the chart in Section 2 unless it did not claim any federal Low Income Program support for any Lifeline consumers prior to June of the current year. If the ETC did not claim support prior to June, the ETC officer must provide the current year and initial the second certification in Section 2.

Column A: Report the number of Lifeline subscribers for which the ETC claimed Lifeline support on its May FCC Form 497 (i.e., the FCC Form 497 for the May data month) for the SAC or SACs listed. If the ETC has more than one SAC in the state covered by this form, the combined total number of subscribers should be entered in Column A.

Column B: If the ETC is acting as a wholesaler and provides Lifeline service to wireline resellers pursuant to section 251(c)(4), report the number of such lines provided to resellers.

Column C: Report the number of Lifeline subscribers the ETC contacted directly to obtain re-certification of eligibility. Enter zero if the ETC relied solely on methods other than direct contact with consumers (e.g., consulting a state database or relying on a Lifeline administrator) to re-certify eligibility.

Column D: Report the number of Lifeline subscribers that responded to the ETC’s request to re-certify their eligibility for Lifeline. This number could be equal to the number in Column C (if every consumer contacted responded) or less than the number reported in Column C (if not every consumer contacted responded).

Column E: Report the number of subscribers who did not respond to the ETC’s request to re-certify eligibility. This number should equal the number reported in Column C minus the number reported in Column D.

Column F: Report the number of subscribers contacted who responded and indicated that they are no longer eligible. Do not include in Column F any consumers who failed to respond to the ETC’s contact.

Column G: Report the number of subscribers that have been, or are scheduled to be, de-enrolled. A subscriber that fails to re-certify continued eligibility must be de-enrolled from Lifeline pursuant to 47 C.F.R. §54.410 (f)(5). The number reported in Column G should include the number of subscribers who did not respond to the ETC’s request to re-certify eligibility, which was reported in Column E, plus the number of subscribers who responded and indicated that they are no longer eligible, as was reported in Column F.

Column H: Report the number of subscribers – of those contacted directly by the ETC in an attempt to re-certify eligibility – who de-enrolled from Lifeline prior to the ETC’s attempt to re-certify continued eligibility. This number should include all subscribers who de-enrolled for any reason, including those subscribers that discontinued Lifeline service with the ETC on their own initiative and those that the ETC de-enrolled from Lifeline (for example, those de-enrolled for non-usage).

Column I: Report the number of consumers for which the ETC relied on a source other than direct contact with the consumer to confirm continued eligibility. An ETC can rely on a state or national database to confirm a consumer continued to be eligible for Lifeline. An ETC can also rely on a Lifeline administrator to confirm consumer eligibility. An ETC must report the number of consumers for which it relied on either of these methods (confirmation through database or Lifeline administrator) in Column H.

Column J: Report the number of subscribers found to be ineligible via confirmation through a database or from a Lifeline administrator. That is, of the number of subscribers for which the ETC or Lifeline administrator utilized a database to attempt to confirm eligibility, how many were found to be ineligible. If any of these subscribers are subsequently contacted directly by the ETC in an attempt to recertify eligibility, those subscribers should be listed in columns C through H as appropriate and not in columns J or K.

Column K: Report the number of subscribers who were de-enrolled, or are scheduled to be de-enrolled, from Lifeline because they were found to be no longer eligible after the ETC consulted a database or relied on a Lifeline administrator. This number should equal the number reported in Column J.

Column L: Report the number of subscribers – of those for which the ETC attempted to verify eligibility via a database or through a Lifeline administrator – who de-enrolled from Lifeline prior to the ETC’s attempt to re-certify continued eligibility. This number should include all subscribers who de-enrolled for any reason, including those subscribers that discontinued Lifeline service with the ETC on their own initiative and those that the ETC de-enrolled from Lifeline for reasons unrelated to the re-certification process (for example, those de-enrolled for non-usage).

The SAC or SACs for which this certification is made must be listed. List multiple SACs only if the ETC has more than one SAC in the state for which the certification is made. Complete additional Annual Lifeline Eligible Telecommunications Carrier Certification Forms for SACs in other states.

Section 3:

An officer of the ETC must certify that the company is in compliance with federal Lifeline certification procedures, that he or she is an officer of the company, and that he or she is authorized to make this certification for the SACs listed on the Annual Lifeline Eligible Telecommunications Carrier Certification Form.

All ETCs must complete Section 3.

Section 4:

Section 4 requires certain ETCs to report by month the number of Lifeline customers de-enrolled as a result of non-usage. 47 C.F.R. §54.405(e)(3) requires ETCs that do not assess or collect a monthly fee from their subscribers to de-enroll subscribers who do not use their Lifeline service for 60 consecutive days plus a 30 day period after notice of potential de-enrollment for non-use is provided. ETCs that do not assess or collect a monthly fee from their Lifeline customers must complete Section 4.

Column N: Report the number of subscribers de-enrolled for non-usage by month.

Signature Fields

Signature of Officer

Provide the signature of an officer of the ETC who is authorized to make the certifications included in the Annual Lifeline Eligible Telecommunications Carrier Certification Form for the SAC(s) listed on the Form.

Printed Name of Officer

Provide the name of the ETC officer who signed the Annual Lifeline Eligible Telecommunications Carrier Certification Form.

Title of Officer

Provide the title of the ETC officer who signed the Annual Lifeline Eligible Telecommunications Carrier Certification Form.

Date

Provide the date the ETC officer signed the Annual Lifeline Eligible Telecommunications Carrier Certification Form.

Person Completing This Certification Form

Provide the name of the ETC employee who populated the form with the data submitted by the ETC.

Contact Phone Number

Provide the phone number of the ETC employee who completed the form.

Persons willfully making false statements on this form can be punished by fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. §1001.

PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS

The FCC is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. If we believe there may be a violation or a potential violation of a FCC statute, regulation, rule or order, your certification may be referred to the Federal, state or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order. In certain cases, the information in your certification may be disclosed to the Department of Justice or a court or adjudicative body when a) the FCC; or b) any employee of the FCC; or c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding.

We have estimated that this collection of information will take 15 hours annually. Our estimate includes the time to read the instructions, look through existing records, gather and maintain required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, Office of Managing Director, AMD‑PERM, Washington, DC 20554, Paperwork Reduction Act Project (3060‑0819). We will also accept your PRA comments if you send an e-mail to [email protected].

Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number and/or we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060‑0819.

THIS NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. SECTION 552a(e)(3) AND THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.