FCC Form 555

F CC Form 555 Revisions Pending OMB Approval

OMB Control No. 3060-0819

October 2014

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)

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)

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.

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: All ETCs MUST COMPLETE SECTION 1– Initial Certification

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

A) 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 or

B) 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(s) listed above. Initial ___

Section 2: All ETCs MUST COMPLETE SECTION 2– Annual Recertification

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

A	B	C
Number of Subscribers Claimed on February FCC Form(s) 497 of current Form 555 calendar year	Number of Lines Claimed on February FCC Form(s) 497 of current Form 555 calendar year provided to Wireline Resellers	Number of Subscribers claimed on the February FCC Form(s) 497 that were initially enrolled in current Form 555 calendar year

Initial the certifications below that apply to your ETC and complete the tables corresponding to the certification below. Depending on the state, BOTH CERTIFICATION A AND B MAY APPLY.

1. I certify that the company listed above has procedures in place 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 got Lifeline. 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 ___

D	E	F =D-E	G	H = (F+G)	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	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

AND/OR

In the space below, 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 or the Universal Service Administrative Company (USAC) and indicate for which qualifying programs (e.g., SNAP, SSI) these sources are used to verify subscriber eligibility. If any of subscribers are subsequently contacted directly by the ETC in an attempt to recertify eligibility, those subscribers should be listed in columns D through I as appropriate and not in columns J through L.

2. I certify that the company listed above has procedures in place to re-certify consumer eligibility by relying on _____________________________________________________________________________ prior to enrolling a subscriber in the Lifeline program. 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 ____

J	K	L
Number of Subscribers Whose Eligibility was Reviewed By State Administrator ETC Access to Eligibility Data 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 Data or USAC	Number of Subscribers Who De-Enrolled Prior to Recertification Attempt

OR

3. 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 Study Area(s) listed above. Initial ____

Section 3: ALL ETCS MUST COMPLETE SECTION 3 –De-enroll percentage

What is the percentage of subscribers de-enrolled for this ETC?

M	N	O	P = N + O	Q = ((P ÷ M) * 100)
Number of Subscribers Claimed on February FCC Form(s) 497 (From Column A)	Number of Subscribers De- Enrolled or Scheduled to be De-Enrolled as a Result of Non-Response or Ineligibility (From Column H)	Number of Subscribers De- enrolled or Scheduled to be De-Enrolled as a Result of a Finding of Ineligibility (From Column K)	Total Number of Subscribers De-enrolled or Scheduled to be De-enrolled	Percentage of Subscribers De-enrolled or Scheduled to be De-enrolled that were Claimed on the February FCC Form(s) 497

Section 4: ALL ETCS MUST COMPLETE APPROPRIATE CHECK BOX; PRE-PAID ETCS MUST COMPLETE ALL OF SECTION 4

Is the ETC Pre-Paid?

Yes No (A Pre-Paid ETC does not assess or collect a monthly fee from its Lifeline subscribers)

If yes, record the number of subscribers de-enrolled for non-usage by month in column S below.

Non-Usage Results Applicable to Pre-Paid ETCs:

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

Signature Block: ALL ETCS MUST COMPLETE SIGNATURE FIELDS

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(s) listed above.

Signed,

_{Signature of Officer Printed Name of Officer}

_{Title of Officer Date}

Person Completing this Certification Form Contact Phone Number

_{ETC Identification}

SAC	ETC Name

_{Holding Company Name(s)}

SAC	Holding Company Name

DBA, Marketing or Other Branding Name(s)

SAC	Name

Affiliated ETCs

SAC	Name