Low-Income Telephone And Electric Discount Programs (Lite-Up) Enrollment Form (Page 2 of 4) in pdf

SECTION 1 –Applicant Information

The person whose name is on the Telephone and Electric bills MUST fill out this section. The person in whose name the utility

bills appear must live at the service address.

Name of Telephone Customer: __________________________________________________________________

As it appears on your utility bill

(please print)

Name of Electric Customer: _____________________________________________________________________

If different from above

(please print)

Mailing Address: _____________________________________

Home Address: ____________________________________

Required if Mailing Address is a PO Box

City: ________________________ Zip Code: ____________

City: _________________________ Zip Code :____________

Telephone Number: ( __ __ __ ) __ __ __ - __ __ __ __

Social Security Number: __ __ __ - __ __ - __ __ __ __

(Required)

Email Address: _____________________________________

Birth Date (Required): ___________________________

YOU MUST:

1. Complete & sign the Lite-up Texas Lifeline Certification Form

2. Complete both pages of the Lite-up Texas Application & sign page 1

3. Provide proof of your eligible Benefits or total Household Income

4. Include a copy of your latest Telephone and Electric bills

If you do not provide the above documentation, you will not be able to get the Lifeline (telephone) discount.

Declaration

(please read carefully and sign)

I certify that my household is receiving only one lifeline discount. I understand that violation of the one-per-household requirement

is against the Federal Communication Commission’s rules and may result in me losing my Lifeline benefits, and potentially,

prosecution by the United States government.

I certify under penalty of perjury that my household receives a qualified benefit or my household has income at or below program

guidelines and that I presented documentation that accurately represents my household income or participation in a qualified

benefit program.

I certify that the information I have provided in this application is true and correct and I agree to participate in the Lite-up Texas

program should I be eligible. I understand that the information provided is subject to audit and investigation by the Public Utility

Commission of Texas.

KEd/Eh

dK W '

________________________________________ Date: ___________________

Applicant’s Signature

Mail completed application and required documentation to:

LITE-UP Texas

1779 Wells Branch Parkway

Suite 110B #357

Austin, Texas 78728-7022

FAX: 1-877-215-8018

Low-Income Telephone And Electric Discount Programs (Lite-Up) Enrollment Form Page 2

Related Articles

Related forms

Related Categories