Form FCC Form 555 FCC Form 555 Description of Services Requested and Certification - Fi

FCC Form 555

[Month] 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.	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	Number of subscribers de-enrolled voluntarily and for non-usage	A user must report the number of subscribers de-enrolled for non-usage by month as well as a total for the number of subscribers de-enrolled from non-usage for the year.
13	Check box indicating ETC is pre-paid	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.
14	Block A - Number of subscribers eligible for recertification by anniversary month	A user must report the number of subscribers eligible for recertification based on the anniversary month of their service activation
15	Block B– 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) or by a state administrator.
16	Number of subscribers due for recertification by month	A user must report the number of Lifeline subscribers who are due for recertification efforts by month (January – December).
17	Block C - Total number of subscribers ETC is responsible for recertifying	A user must report the total number of subscribers it is responsible for recertifying
18	Block D – Number of subscribers whose eligibility was reviewed and who were recertified by access to state or federal eligibility database or process	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.
19	Block E - State or federal database or process used	If applicable, the user must identify the state or federal database or process used for recertification efforts
20	Block F – Number of subscribers ETC contacted for purpose of recertification	A user must report the number of Lifeline subscribers the ETC contacted directly to obtain recertification of eligibility.
21	Block G – Number of subscribers to be de-enrolled by ETC recertification efforts by month (subscribers who failed to be recertified)	A user must report by month 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.
22	Block H – Number of subscribers responding to recertification request (that were successfully recertified)	A user must report the number of Lifeline subscribers that responded to the ETC’s request to recertify their eligibility for Lifeline.
23	Block I – Number of subscribers whose eligibility was reviewed by a state administrator, USAC or another third party entity for the purposes of recertification	A user must report the number of Lifeline subscribers whose eligibility was reviewed by and/or who were contacted by USAC, a state administrator or another third party for the purpose of recertification
24	Block J – Name of third party entity who reviewed eligibility and/or contacted the subscriber	A user must report the name of the third party entity who reviewed eligibility and/or contacted the subscriber for the purpose of recertification
25	Block K – Number of subscribers to be de-enrolled by state administrator, USAC or other third party recertification efforts by month	A user must report by month the number of subscribers that have been, or are scheduled to be, de-enrolled as a result of non-response or ineligibility from state administrator, USAC or another third-party recertification effort.
26	Block L – Number of subscribers responding to a state administrator, USAC or another third party’s recertification request (that were successfully recertified)	A user must report the number of Lifeline subscribers that responded to a state administrator, USAC or another third party’s request to recertify their eligibility for Lifeline.
27	Number of subscribers to be de-enrolled by state or federal database recertification efforts by month	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 process.
28	Block M – Total 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. This information will be pre-populated.
29	Block N - Total number of subscribers ETC is responsible for recertifying	A user must report the total number of subscribers ETC is responsible for recertifying
30	Block O – Percent of subscribers due for recertification who were de-enrolled due to the month’s recertification efforts	A user must report the percent of subscribers who were de-enrolled due to the month’s recertification efforts. This block will be pre-populated.
31	Certifying Officer Signature	ETCs certifying officer must sign to certify the company listed is in compliance with all federal Lifeline certification procedures.
32	Printed Name and Title of Officer	This is the name of the authorized person certifying the form.
33	Email Address of Officer	This is the email address of the authorized person signing the form.
34	Date	User must provide the date form was completed. This field will be pre-populated.
35	Person Completing Form	This is the name of the authorized person completing the form if different then the officer certifying the form.
36	Contact Phone Number	User must provide phone contact information for the authorized person completing the form.

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