Low-Income Telephone And Electric Discount Programs (Lite-Up) Enrollment Form (Page 3 of 4) in pdf

SECTION 2 – Income Enrollment Worksheet

HOUSEHOLD SIZE –

Number of people living in your household: _____ (Include all adults and children at this address)

Your total household gross annual income from all sources cannot exceed these guidelines:

Number of persons in Household

Total Household annual income - Telephone

$17,665

$23,895

$30,135

$36,375

$42,615

$48,855

$55,095

$61,335

Total Household annual income - Electric

$14,713

$19,913

$25,113

$30,313

$35,513

$40,713

$45,913

$51,113

Frequency

Type of Income

Dollar Amount

(Monthly, Weekly, etc.)

Wages from Employment as shown on pay stub or W-2 Form

Social Security

Retirement Income

Alimony or Child Support

Unemployment or Worker’s Compensation

All Other Earnings

IF YOU ARE QUALIFYING USING YOUR TOTAL HOUSEHOLD INCOME YOU MUST PROVIDE PROOF OF

HOUSEHOLD INCOME WITH THIS APPLICATION (provide all documents that apply)

•

Copy of most recent pay stub(s) from all employers covering the last two months for all members of the household

•

Your most recently filed tax return (must be signed) or W-2 form

•

A signed letter from each employer indicating the level of your wage

•

Documentation of social security income

•

Copy of an unemployment form with eligibility dates

•

Copies of the two most recent unemployment checks

•

Copy of the most recent bank statement showing direct deposit of income (for SSI, Social Security, annuity, pension)

SECTION 3 – Program Benefit Enrollment Worksheet

Qualified Benefits

Any Household Member who is eligible for any of these benefits

The applicant must be eligible for either of these benefits

makes the household eligible for the Telephone Discount (Lifeline)

in order to receive the Electric Discount

� SNAP

� Medicaid

� Supplemental Security Income-SSI

� Health Benefit Coverage under Child Health Plan (CHIP)

� Low-Income Energy Assistance Program - LIHEAP

� Federal Public Housing Assistance

� Temporary Assistance for Needy Families (TANF)

� National School Lunch Program - Free Lunch Program

IF YOU ARE QUALIFYING BECAUSE OF ELIGIBILITY IN A QUALIFIED PROGRAM YOU MUST PROVIDE

PROOF OF PROGRAM PARTICIPATION WITH THIS APPLICATION

Copy of an letter from a government agency showing eligibility for the qualified benefit

•

Copy of a Medicaid card for the eligible individual

•

Federal Public Housing rental agreement

•

Note: a Lone Star Card is not an eligible document

•

Eligible Resident of Tribal Lands (indicate which tribe): __________________________________________

Provide documentation of tribe affiliation and participation in at least one of the following: Bureau of Indian Affairs General

Assistance, Tribally-Administered Temporary Assistance for Needy Families, Head Start (only those meeting its income qualifying

standard), or the National School Lunch Program’s free lunch program.

Benefit Recipient – Telephone Discount Only

Please provide the name of the person in your household who is receiving one of the eligible benefits listed above.

Note: you must provide proof that this person participates in one of the eligible programs.

Name of Benefit Recipient: _______________________________________________________________________

Low-Income Telephone And Electric Discount Programs (Lite-Up) Enrollment Form Page 3

Related Articles

Related forms

Related Categories