California Lifeline Renewal Form Sample Page 4
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1
2
3
4Did You Remember To:
Call your phone company within 30 days to report any mistakes you see in Step 1.
●
Print your initials in Step 2.
●
Use blue or black pen to fill out your form.
●
Print and SIGN your name below.
●
For faster processing, renew online
at using
your PIN.
Optional
REMOVE ME - Fill in the bubble if you believe you Do Not Qualify for California LifeLine and/or want to
STOP getting the discounts.
SIGN AND PRINT YOUR NAME - By signing below in compliance with federal and state government rules, I certify, under penalty of perjury,
that giving false or fraudulent information is punishable by law, that my household is qualified for the discounts, that my household will not
be getting more than one discount, that the service address is my principal residence, that I am not claimed as a dependent on another
person’s tax return, that I understand the notification rules, that I must renew my discounts annually, that if I do not renew I will lose the
discounts, and that the information in this form is true and correct. I agree to inform my phone company or the California LifeLine
Administrator within 30 days if I change my service address or billing address, if I no longer qualify for the California LifeLine discounts, or
if my household is getting more than one discount. I understand and agree that I will be penalized if I do not follow these notification rules. I
acknowledge and give my consent for the California LifeLine Administrator to share my information in this form to the Universal Service
Administrative Company and/or its agents. Legal Guardians or people with Power of Attorney are allowed to sign this form.
X
Participant’s Signature (REQUIRED)
Today’s Date:
Month
Day
Year
Fill in this bubble if signed by a Legal Guardian or a person with Power of Attorney.
Participant’s Date of
The LAST 4 digits of the Participant’s
Birth:(REQUIRED)
Social Security Number (REQUIRED):
Month
Day
Year
Last 4 digits
Participant’s First and Last Name (REQUIRED: Must match the name from Step 1 under Permanent Service Address)
(Optional) Fill in the bubble next to your choice for future notifications.
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ST EN 10 #R RN 1.0 08-12
MH1705500370
Page 6 of 8
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