FCC Forms 555 and 481

FCC Form 555

July 2016

OMB Approval

3060-0819

Lifeline/Low Income Universal Service

Description of Services Requested and Certification Form 555

(Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual representation of what each applicant will see).

Item Number	Field Description	Purpose/Instructions
1	Study Areas Code (SAC)	This is the unique USAC identifier for the ETC submitting the filing. Each ETC must provide a separate FCC Form 555 for each SAC used to provide Lifeline service.
2	Service Provider Identification Number (SPIN)	User must provide the nine-digit Service Provider Identification Number (SPIN) for which the certification is being filed. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
3	Recertification Year	To create a unique identifier for this submission to determine which calendar year the form is being filed.
4	State	User must list the name of the corresponding state(s) for which the ETC is filing this certification. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
5	ETC Name	User must enter the corporate name of the ETC submitting the.
6	Holding Company Name(s)	User must list corporate name of the holding company of the ETC.
7	DBA, Marketing or Other Branding Name(s)	A user must list 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 for the SAC reported on this Form.
8	Affiliated ETC’s SAC	If the user selected Yes indicating they have affiliated ETCs, the user must provide a list of all ETCs that are affiliated with the reporting ETC in the space provided.
9	Affiliated ETC’s Name	User is required to provide a list of all ETCs that are affiliated with the reporting ETC, using page 4 and additional sheets, if necessary. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
10	Initial Certification: 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; and/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 Code listed above.	Requires an officer of an ETC to certify that the ETC verifies consumer eligibility prior to enrolling a consumer in Lifeline by reviewing income and program-based eligibility documentation and/or confirming the consumer’s eligibility by relying upon access to a state database and/or notice of eligibility from the state Lifeline administrator.
11	Section 2 Certifications: 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. 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. 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.	Requires a user to certify that the ETC has procedures in place to recertify the continued eligibility of all of its Lifeline subscribers, and that, to the best of the user’s knowledge, the company obtained signed certifications from all subscribers attesting to their continuing eligibility for Lifeline.
12	Block A – Number of subscribers claimed on February FCC Form 497	A user must report the number of Lifeline subscribers for which the ETC claimed Lifeline support on its February FCC Form 497 for the current Form 555 calendar year (i.e., the FCC Form 497 for the February data month) for the SAC listed.
13	Block B – Number of resale lines claimed on February FCC Form 497	If the ETC is acting as a wholesaler and provides Lifeline service to wireline resellers pursuant to section 251(c)(4), user must report the number of such lines provided to resellers.
14	Block C – Number of subscribers claimed on February FCC Form 497 that were enrolled in current calendar year	A user must report the number of Lifeline subscribers for which the ETC claimed Lifeline support on its February FCC Form 497 for the current Form 555 calendar year that were initially enrolled in Lifeline in that year.
15	Block D – Number of subscribers de-enrolled prior to recertification attempts	A user must report the number of subscribers who de-enrolled from Lifeline prior to the ETC’s attempt to recertify continued eligibility, either directly, through the use of a third-party administrator (such as USAC), by a state administrator, or by access to a state eligibility database.
16	Block E – Number of subscribers the ETC must recertify	A user must report the number of subscribers the ETC was responsible for recertifying for the current Form 555 calendar year. This information is pre-populated based on the user’s previous responses.
17	Block F – Number of subscribers recertifying through attestation	A user must report the number of Lifeline subscribers the ETC contacted directly to obtain recertification of eligibility.
18	Block G – Number of subscribers responding to attestation request	A user must report the number of Lifeline subscribers that responded to the ETC’s request to recertify their eligibility for Lifeline.
19	Block H – Number of non-responding subscribers	A user must report the number of subscribers who did not respond to the ETC’s request to recertify eligibility. This information is pre-populated based on the user’s previous responses.
20	Block I – Number of subscribers responding they are no longer eligible	A user must report the number of subscribers contacted who responded and indicated that they are no longer eligible.
21	Block J – Number of subscribers to be de-enrolled by ETC recertification	A user must report the number of subscribers that have been, or are scheduled to be, de-enrolled as a result of non-response or ineligibility from the ETC recertification effort. This information is pre-populated based on the user’s previous responses.
22	Block K – Number of subscribers whose eligibility was reviewed by state administrator, ETC access to eligibility database, or by USAC	A user must report the number of consumers for which the ETC relied on a source other than direct contact with the subscriber to confirm continued eligibility.
23	Block L – Number of subscribers to be de-enrolled by third-party recertification	A user must list the number of subscribers that were de-enrolled, or are scheduled to be de-enrolled, as a result of ineligibility found via confirmation through a state database or a Lifeline administrator.
24	Block M – Number of subscribers the ETC attempted to recertify directly or by a third-party	A user must report the number of subscribers that the ETC attempted to recertify directly or through a state administrator, ETC access to a state database, or by USAC. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
25	Block N – Number of subscribers de-enrolled or scheduled to be de-enrolled as a result of non-response or ineligibility	A user must report the number of subscribers de-enrolled or scheduled to be de-enrolled as a result of non-response or ineligibility. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
26	Block O – Percentage of subscribers de-enrolled or scheduled to be de-enrolled as a result of ineligibility or non-response	A user must report the percentage of subscribers de-enrolled or scheduled to be de-enrolled as a result of ineligibility or non-response. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
27	Block P – Non-usage months	Block P is pre-populated with the months of the year.
28	Block Q – Number of subscribers de-enrolled for non-usage	A user must report the number of subscribers de-enrolled for non-usage for that month as well as a total for the number of subscribers de-enrolled from non-usage for the year.
29	ETC Prepaid Indicator/Subject to Non-Usage Requirements	Users must complete the appropriate check-box to indicate whether their ETC is pre-paid or not. If an ETC is pre-paid, they are subject to the non-usage requirements. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
30	Certifying Officer Signature	ETCs certifying officer must sign to certify the company listed is in compliance with all federal Lifeline certification procedures.
31	Printed Name and Title of Officer	This is the name of the authorized person certifying the form.
32	Email Address of Officer	This is the email address of the authorized person signing the form.
33	Date	User must provide the date form was completed. This field will be pre-populated.
34	Person Completing Form	This is the name of the authorized person completing the form if different then the officer certifying the form.
35	Contact Phone Number	User must provide phone contact information for the authorized person completing the form.

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