FCC Forms 555 and 481

FCC Form 555

July 2016

OMB Approval

3060-0819

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).

Recertification Year 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

Annual Lifeline Eligible Telecommunications Carrier Certification Form

Instructions

1. Submit to the Universal Service Administrative Company (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. Email to LiVerifications@usac.org.

4. Mail to USAC using the address below.

USAC

Lifeline Program

700 12th Street NW, Suite 900

Washington, DC 20005

2. Submit to the FCC via the Electronic Comment Filing System in Docket WC 14-171 at

http://apps.fcc.gov/ecfs/upload.

3. Complete the data fields and certifications on the Form according to the following instructions.

Study Area Code (SAC)

Enter the six-digit study area code (SAC) for which the certification is being filed. An eligible telecommunications carrier (ETC) must provide a separate Annual Lifeline Eligible Telecommunications Carrier Certification Form for each SAC used to provide Lifeline service. ETCs are not permitted to include multiple SACs on one form.

Service Provider Identification Number (SPIN)

Enter the nine-digit Service Provider Identification Number (SPIN) for which the certification is being filed. ETCs are not permitted to include multiple SPINs on one form.

Recertification Year

Enter the calendar year for which the ETC’s annual recertification results are being submitted. For example, if subscribers from an ETC’s February 2015 FCC 497 Form were subject to recertification, the Recertification Year for the Form 555 containing the results of the ETC’s efforts would be 2015.

State

Enter the corresponding state(s) for which the ETC is filing this certification. (In some instances, a SAC may cover more than one state.)

ETC Name

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

DBA, Marketing 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 for the SAC reported on this Form. If the DBA/Marketing/Branding name does not differ from the ETC name, enter “N/A.” Do not leave this field blank.

Holding Company Name(s)

Enter the corporate name of the holding company of the ETC. If the Holding Company name does not differ from the ETC name, enter N/A. Do not leave this field blank.

Affiliated ETCs

Check the “Yes’ or “No” box if the ETC reported on the Form has affiliated ETCs. Affiliation shall be determined in accordance with Section 3(2) of the Communications Act. See 47 U.S.C. § 153(2). 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.

If the ETC selected Yes, it must provide a list of all ETC that are affiliated with the reporting ETC in the space provided. Use the additional space at the end of the Form, if necessary.

Section 1: Initial Certification

All ETCs must complete Section 1. Section 1 requires an officer of an ETC to certify that the ETC verifies consumer eligibility prior to enrolling a consumer in Lifeline by A) reviewing income and program-based eligibility documentation and/or B) confirming the consumer’s eligibility by relying upon access to a state database and/or notice of eligibility from the Lifeline administrator. An Officer of the company must certify this section by providing their initials on the line provided.

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 2: Annual Recertification

All ETCs must complete Section 2 and must initial next to the certifications that apply for the SAC. Depending on the SAC, an ETC may complete 1) Certification A or Certification B, 2) both Certifications A and B, or 3) only Certification C.

Section 2 requires that the results of the ETC’s annual recertification be recorded. All ETCs must complete Blocks A-L for the SAC for which the filing is being made. If an ETC has nothing to report in a Block, enter a zero. DO NOT LEAVE EMPTY BLOCKS.

Block A

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. If the ETC did not claim support on its February FCC Form 497 for the reported SAC, the ETC should enter zero in Block A.

Block 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. If the ETC does not provide service to wireline resellers, the ETC should enter zero in Block B.

Block C

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. For example, for the 2014 Form 555 calendar year, if an ETC claimed 100 subscribers on its February 2014 FCC Form 497 and 10 of those subscribers initially enrolled in the Lifeline program in January or February 2014 (that is, they did not have service as of December 31, 2013), then the ETC should enter 10 in Block C.

Block D

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. 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). If no subscribers were de-enrolled from Lifeline prior to the recertification attempt, the ETC should enter zero in Block D.

Block E

Report the number of subscribers the ETC was responsible for recertifying for the current Form 555 calendar year. This number should be the result of the following calculation: E=A-B-C-D. This field will auto-calculate for online filers.

Block F

Report the number of Lifeline subscribers the ETC contacted directly to obtain recertification of eligibility. Enter zero if the ETC relied solely on methods other than direct contact with subscribers (e.g., consulting a state database or relying on a Lifeline administrator) to recertify eligibility. If the eligibility of any subscriber was reviewed through the use of a state database or state administrator and subsequently contacted directly by the ETC in an attempt to recertify eligibility, those subscribers should be recorded in Block F through J as appropriate and not in Blocks K and L. All subscribers subject to recertification, calculated in Block E, must be accounted for in Block F or Block K. The total of Blocks F and K should equal the number reported in Block E.

Block G

Report the number of Lifeline subscribers that responded to the ETC’s request to recertify their eligibility for Lifeline. This number should be equal to the number in Block F (if every subscriber contacted responded) or less than the number reported in Block F (if not every subscriber contacted responded). Enter zero if the ETC relied solely on methods other than direct contact with subscribers (e.g., consulting a state database or relying on a Lifeline administrator) to recertify eligibility, or if no subscriber responded.

Block H

Report the number of subscribers who did not respond to the ETC’s request to recertify eligibility. This number should equal the number reported in Block F minus the number reported in Block G. 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 recertify eligibility, or if 100 percent of subscribers contacted responded. This field will auto-calculate for online filers.

Block I

Report the number of subscribers contacted who responded and indicated that they are no longer eligible. Do not include in Block I any consumers who failed to respond to the ETC’s direct contact. Enter zero if the ETC relied solely on methods other than direct contact with subscribers (e.g., consulting a state database or relying on a Lifeline administrator) to recertify eligibility, or if zero subscribers responded and indicated that they were no longer eligible.

Block J

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. A subscriber that fails to recertify continued eligibility must be de-enrolled from Lifeline pursuant to Sections 54.410(f)(5) and 54.405(e)(4) of the Lifeline rules. See 47 C.F.R. §§ 54.410(f)(5), 54.405(e)(4). The number reported in Block J should include the number of subscribers who did not respond to the ETC’s request to recertify eligibility, as reported in Block H, plus the number of subscribers who responded and indicated that they are no longer eligible, as reported in Block I. Enter zero if the ETC relied solely on methods other than direct contact with subscribers (e.g., consulting a state database or relying on a Lifeline administrator) to recertify eligibility, or if 100 percent of the subscribers contacted were successfully recertified. This field will auto-calculate for online filers.

Block K

Report the number of consumers for which the ETC relied on a source other than direct contact with the subscriber to confirm continued eligibility. An ETC can rely on a state database to confirm a subscriber continued to be eligible for Lifeline. An ETC can also rely on a Lifeline state administrator to confirm consumer eligibility or on USAC in those instances where the ETC has elected USAC to perform the recertification. An ETC must report the number of subscribers for which it relied on any of these methods in Block K.

If any subscribers are 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 Block K. ETCs should be careful not to double count these subscribers. Enter zero if the ETC relied solely on direct contact with subscribers to recertify eligibility.

ETCs electing to use USAC to perform their recertification should NOT also attempt to recertify subscribers on their own. ETCs should NOT enter any subscribers recertified by USAC in Blocks F through J.

Block L

Report 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. As stated above, if any of these subscribers are 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 Block L. ETCs should be careful not to double count these subscribers.

Section 2 Certifications

An officer of the ETC must initial at least one of the certifications. Depending on the SAC, an ETC may complete 1) Certification A or Certification B, 2) both Certifications A and B, or 3) only Certification C. If Certification C applies, neither Certifications A nor B apply. The certification that the officer of the ETC has initialed should correspond to the results data as reported in Blocks F-L.

Certification A: An officer of the ETC must initial Certification A in Section 2 if the ETC verifies consumer eligibility by reviewing documentation provided by the consumer.

Certification B: An officer of the ETC must initial Certification B in Section 2 if the ETC verifies consumer eligibility by relying on information provided by a state database, state Lifeline administrator, or USAC in those instances where the ETC has elected to use USAC to perform the recertification. In the blank, provide the data source or sources used to verify consumer eligibility. For example, data sources can include the name of a state database an ETC queried to confirm consumer eligibility or the name of a state Lifeline administrator that provided notice of consumer eligibility to the ETC.

Certification A and B: An officer of an ETC that uses multiple methods of confirming ongoing consumer eligibility should initial both Certification A and B. 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 initial both Certifications A and B in Section 2.

Certification C: An officer of the ETC must initial Certification C if the ETC did not claim federal Low Income support for any Lifeline subscribers for February FCC Form 497 data month for the current Form 555 calendar year.

Section 3: De-enroll Percentage

All ETCs must complete Section 3. Section 3 requires the ETC to calculate the percentage of de-enrolled subscribers for the ETC using the recertification results entered in Section 2. ETCs should enter zero instead of a blank for Blocks for which there is no result. For online filers, these fields will be auto calculated.

Block M

Enter the number of subscribers that the ETC attempted to recertify directly or through an administrator, access to a database or by USAC by calculating the sum of the numbers entered in Block F and Block K. This number should equal the number entered in Block E (number of subscribers the ETC is responsible for recertifying). If the ETC entered zero in both Blocks F and K, it should also enter zero in Block M.

Block N

Enter the number of subscribers de-enrolled or scheduled to be de-enrolled as a result of non- response or ineligibility. This number should equal the sum of the numbers entered in Block J and Block L. If the ETC entered zero in both Blocks J and L, the ETC should also enter zero in Block N.

Block O

Enter the percentage of subscribers de-enrolled, or scheduled to be de-enrolled, as a result of non- response or ineligibility to the recertification attempt by dividing Block N by Block M and multiplying the result by 100.

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 that only assess a fee, but do not collect such fees are also subject to the non-usage requirements. If the ETC selects yes, the ETC must report by month the number of Lifeline customers de-enrolled as a result of non-usage. Section 54.405(e)(3) of the Lifeline rules requires ETCs that do not assess and collect a monthly fee from their subscribers to de-enroll subscribers who do not use their Lifeline service for 30 consecutive days. Section 54.405(e)(3) requires ETCs to provide such subscribers with a 15-day notice stating that their service will be terminated if they fail to use their service within the subsequent 15 days. ETCs that do not assess or collect a monthly fee from their Lifeline customers must complete Section 4.

Block P

Block P is pre-populated with the months of the year.

Block Q

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.

Signature Fields

An ETC is required to complete all of the Signature Fields for the Form to be considered complete. By doing so, the ETC certifies that the company is in compliance with all federal Lifeline certification procedures.

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 listed on the Form.

Printed Name and Title of Officer

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

Email Address of Officer

Provide the email address 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 PRA@fcc.gov.

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.

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