Annual Lifeline Eligible Telecommunications Carrier Certification Form printable pdf download

FCC Form 555

Approved by OMB

3060-0819

November 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

(Annually)

Study Area Code (SAC)

(An Eligible Telecommunications Carrier (ETC) must provide a certification form for each SAC through which it provides Lifeline service).

State

ETC Name

DBA, Marketing or Other Branding Name

Holding Company Name

(If same as ETC name, list “N/A” Do not leave blank)

Does the reporting company have affiliated ETCs?

Yes

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:

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.

Initial

Annual Lifeline Eligible Telecommunications Carrier Certification Form