Form Application For Lifeline Telephone Service Credit - State Of Vermont - 2011

L

Application for Lifeline

ifeLine

2011 VERMONT

Telephone Service Credit

You may be eligible for a credit of at least $13.00 toward payment of your monthly Vermont basic telephone

charge. To apply, return this form by June 15, 2012. You must reapply for the credit each year.

If you will be 65 or OLDER by June 15, 2012.

If you will be UNDER 65 on June 15, 2012.

OR

Complete this checklist to see if you are eligible:

Complete this checklist to see if you are eligible:

Are you a Vermont resident? c Yes c No

Are you a Vermont resident? c Yes c No

Will you be at least 65 by June 15, 2012? c Yes c No

Will you be younger than 65 on June 15, 2012? c Yes c No

Was your 2011 household income for you and your spouse less than

Was your 2011 household income for you and your spouse less than

No

$25,743 (from Income section below, Line p.)? c Yes c No

$22,065 (from Income section below, Line p.)? c Yes c

If you answer “Yes” to all questions, you are eligible.

If you answer “Yes” to all questions, you are eligible.

The following section must be filled out completely or your application will be returned and benefits will be delayed.

Your Name _________________________________________________

Spouse or CU Partner Name ________________________________________________

Name on phone bill ___________________________________________

Name of your telephone company ____________________________________________

Telephone Number

Street, P.O. Box or RD __________________________________________________________________________

–

City __________________________________________ State _______ Zip Code ________________________

Social Security Number

Birthdate

Sex

–

–

Month

Day

Year

F/M

Yours

Yours

–

–

Spouse or

Spouse or

CU Partner

CU Partner

INCOME (Total, You and Spouse or CU Partner combined)

a. Cash public assistance/welfare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a. ____________________

b. Social Security/railroad retirement/veteran’s benefits, taxable and nontaxable . . . . . . . . . . . . . . . . . . . . . b. ____________________

c. Unemployment compensation/worker’s compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .c. ____________________

d. Wages, salaries, tips, etc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. ____________________

e. Interest and dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e. ____________________

f. Interest on U.S., state and municipal obligations, taxable and nontaxable . . . . . . . . . . . . . . . . . . . . . . . . . . f. ____________________

g. Alimony, support money/child support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g. ____________________

h. Business income: If you have a loss, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . h. ____________________

i. Capital gains, taxable and nontaxable. If you have a loss, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i. ____________________

j. Pensions and annuities, taxable and nontaxable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . j. ____________________

k. Rental income: If you have a loss, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . k. ____________________

l. Farm/partnership/Subchapter S income: If you have a loss, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l. ____________________

m. Other income. Please specify . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . m. ____________________

n. SUBTOTAL: Add Lines a through m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n. ____________________

o. LESS adjustments to income from Federal Form 1040, Line 36 or 1040A, Line 20 . . . . . . . . . . . . . . . . . . o. ____________________

p. TOTAL INCOME: Subtract Line o from Line n and enter the result here . . . . . . . . . . . . . . . . . . . . . . . . . p. ____________________

o

U

o

c

nr

fficial

se

nly

I declare under penalties of perjury this application is true, correct, and complete to the best of my knowledge. If prepared by a person other than the applicant, this declaration further

provides that under 32 V.S.A. §5901 this information has not been and will not be used for any other purpose, or made available to any other person other than for the preparation of this

application unless a separate valid consent form is signed by the applicant and retained by the preparer. I author ize the VT Department of Taxes to disclose this information

and other information necessary to process the Lifeline Credit to the Secretary of Human Services.

__________________________________________________________________________

______________________________________________________________________

Subscriber’s signature

Date

Signature of preparer if other than taxpayer

Date

__________________________________________________________________________

______________________________________________________________________

Spouse or Civil Union Partner signature (if filing jointly)

Date

Address of preparer

45