Form FCC Form 555 FCC Form 555 Annual Lifeline Eligible Telecommunications Carrier Cert

OMB Control No. 3060-0819
Est. Burden: 16 hours
Form No. 555
Edition: Month 2023
Annual Lifeline Eligible Telecommunications Carrier Certification Form
All carriers must complete all or portions of all sections. The Form 555 must be submitted to USAC and filed with the
Federal Communications Commission.

IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: January 31st (Annually)

Study Area Code (SAC)

Service Provider Identification Number (SPIN)

(An Eligible Telecommunications Carrier (ETC) must provide a certification form for each SAC that 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

1

Initial Certification All ETCs must complete this section.
I certify that the company listed above:
• Has policies and procedures in place to ensure that its Lifeline subscribers are eligible to receive Lifeline services;
and
• Is in compliance with all federal Lifeline certification procedures; and
• Is in compliance with the minimum service levels set forth in 47 C.F.R. § 54.408.
I am an officer of the company named above. I am authorized to make this certification for the SAC listed above.

Initial _________

Annual Recertification Results
Report the results of recertification efforts for the current calendar year.
Do not leave blocks empty. If the National Verifier is responsible for conducting recertification, enter zero for blocks
A - F. If the state Lifeline Administrator is responsible for conducting recertification, report the results for each
block.
A. Subscribers eligible for recertification within current calendar year
B. Subscribers de-enrolled prior to recertification attempts
C. Total number of subscribers required to be recertified (A-B)
D. Subscribers successfully recertified
E. Subscribers de-enrolled for failed recertification
F. Percentage de-enrolled for failed recertification (E/C)

I certify that the company listed above has procedures in place to recertify consumer eligibility by relying upon notice
of eligibility from:

state Lifeline administrator

National Verifier

I am an officer of the company named above. I am authorized to make this certification for the SAC listed above.
Initial _________

No Subscribers Certification Complete this section if ETC claimed no Lifeline subscribers.
I certify that my company did not claim federal low income support for the current Form 555 data year. I am an
officer of the company named above. I am authorized to make this certification for the SAC listed on this form
Initial _________

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. 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 H below.

G
Month
January
February
March
April
May
June
July
August
September
October
November
December
Total Subscribers

H
Subscribers De-Enrolled for Non-Usage

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.

Signature Block
By signing below, I certify that the information provided is true and accurate. I am an officer of the
company named above. I am authorized to make this certification for this SAC.
Signed,
Signature of Officer

Printed Name and Title of Officer

Email Address of Officer

Date

Person Completing This Certification Form

Contact Phone Number