Fillable Membership Application Form printable pdf download

EXHIBIT “A” to Lifeline Eligibility Verification Policy

NORTHEAST RURAL SERVICES, INC. D/B/A BOLT FIBER OPTIC SERVICES

LIFELINE ASSISTANCE APPLICATION

THIS SIGNED APPLICATION IS REQUIRED IN ORDER TO ENROLL YOU IN THE LIFELINE PROGRAM AS APPROVED BY THE FEDERAL

COMMUNICATIONS COMMISSION (FCC). THE FORM IS ONLY FOR THE PURPOSE OF CERTIFYING YOUR ELIGIBILITY FOR THE LIFELINE OR

TRIBAL LINK UP PROGRAM AND WILL NOT BE USED FOR ANY OTHER PURPOSE. PLEASE PRINT USING BLOCK CAPITAL LETTERS IN

BLACK OR BLUE INK ONLY. WHEN COMPLETED, PLEASE MAIL THE FORM AND COPIES OF PROOF OF ELIGIBILITY TO: P.O. BOX 399,

VINITA, OK 74301 ATTN: SHEILA ALLGOOD

(A)

APPLICANT INFORMATION

Full Name:

Residential Address:

Line 1:

City:

State:

ZIP Code:

Is this a Temporary

Date of Birth:

Address (Y/N):

Last Four Digits

Tribal ID (if applicable):

of Social Security

Number:

Billing Address (if different from Residential Address):

Line 1:

City:

State:

ZIP Code:

IMPORTANT DISCLOSURES

•

Lifeline is a government benefit that helps eligible consumers pay for telephone services by discounting their monthly service bill.

Willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the

program.

•

Only one Lifeline service benefit is available per household. A subscriber must be verified by the FCC National Lifeline

Accountability Database (NLAD) before he/she can be enrolled in Lifeline.

•

A household is defined, for purposes of the Lifeline program, as any individual or group of individuals who live together at the same

address and share income and expenses.

•

A household is not permitted to receive Lifeline benefits from multiple providers.

•

Violation of the one-per-household limitation constitutes a violation of FCC rules and will result in the subscriber’s de-enrollment

from the program.



Lifeline is a non-transferable benefit and the subscriber may not transfer his or her benefit to any other person.



Please complete the Lifeline Household Worksheet attached and submit the completed Worksheet with this Application.

National Lifeline Accountability Database (NLAD) Disclosure and Consent

The FCC has ordered the creation of a National Lifeline Accountability Database. Northeast Rural Services, Inc., d/b/a BOLT Fiber Optic

Services (BOLT) must provide the following information to the database in order to ensure the proper administration of the Lifeline

Program:



Your full name

Your full residential address

The date BOLT began providing

you with Lifeline service



Your date of birth

The amount of the discount BOLT

The Future date when your

provides

Lifeline service with BOLT ends



Your telephone number

Whether your eligibility is program or

The last four digits of your Social

income based

Security Number (or Tribal ID)

By my initials and by signing this application, I confirm I have read and understand the disclosures provided above and hereby consents

to BOLT’s release of any of my information contained in this Lifeline Application required for the administration of the Lifeline program to

the FCC or its designee, including the Universal Service Administrative Company, and to any state and federal agency or its designee, as

required by law. (Failure to provide consent will result in being denied Lifeline service.)

Applicant’s Initials: _______

CONTINUED ON NEXT PAGE

(B) ELIGIBILITY REQUIREMENTS

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