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

Low-Income Telephone and Electric Discount Programs (LITE-UP) Lifeline Certification Form

Full Name: ___________________________________________

You must provide this information:

Home Address

: _______________________________

Date of Birth

: ___________________

(mm/dd/yyyy)

(No PO box)

Social Security Number/Tribal ID#: ___________________

City: _____________________________ Zip Code:__________

Telephone # Receiving Lifeline Service: _________________

Billing Address: ________________________________________

Telephone Provider: ________________________________

City: _____________________________ Zip Code: __________

This is a Temporary Address: Yes _____ No _____

ONLY ONE LIFELINE BENEFIT IS ALLOWED PER HOUSEHOLD

YOU COULD LOSE YOUR LIFELINE BENEFIT IF YOU VIOLATE THIS RULE

Lifeline is a government program that provides a monthly discount on home or wireless telephone services, but not both. Only one Lifeline

service is allowed per household; a household is not permitted to receive Lifeline benefits from multiple providers. Your household is

everyone who lives in your home (including children and people who are not related to you) and shares income and household expenses

(bills, food, etc.). Violation of the one-per household rule is a violation of federal rules and will result in de-enrollment from the Lifeline

program and potential prosecution by the United States Government. You may not transfer your Lifeline benefit to any other person.

Please initial the certifications below and sign and date this form.

I certify, under penalty of perjury, that:

I meet the income-based eligibility criteria (household income less than 150% of federal poverty guidelines). Please state

the number of household members: _____________

Or I meet the program-based eligibility criteria for receiving Lifeline. Check Benefits that apply:

 SNAP,  Medicaid,  SSI,  Federal Public Housing Assistance,  LIHEAP,  TANF,

 CHIP,

 National School Lunch Program – Free Lunch Program

_______

I will notify my telephone carrier and the Lite-up Texas Program within 30 days if for any reason I no longer satisfy the

criteria for receiving Lifeline, or if I no longer meet the income-based or program-based criteria for receiving Lifeline

support, or if I am receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline

benefit.

_______

If I move to a new address, I will provide that new address to my Lifeline carrier and the Lite-up Texas Program within 30

_______

days.

(Only if applicable) If I provided a temporary residential address to the eligible telecommunications carrier and the Lite-up

_______

Texas Program, I am required to verify my temporary residential address every 90 days.

My household will receive only one Lifeline service and, to the best of my knowledge, my household is not already receiving

#5 _______

a Lifeline service.

I may be required to re-certify continued eligibility for Lifeline at any time, and that failure to do so will result in de

#6 _______

enrollment and the termination of my Lifeline benefit.

#7 _______

I will not transfer the Lifeline benefit to anyone else, including any other eligible person.

I consent to allow my personal identification information to be shared with the Universal Service Administrative Company

#8 _______

(USAC) and/or its agents for the purpose of verifying that I am not receiving more than one Lifeline benefit.

#9 _______

(Only if applicable) If I am seeking to qualify for Lifeline as an eligible resident of Tribal lands, I live on Tribal lands.

By signing this document, I certify, under penalty of perjury, to the items initialed above and that I understand the Lifeline program rules

described above and agree to participate in the Lifeline program should I be eligible, that the information I have provided on this form is true and

correct to the best of my knowledge and that providing false or fraudulent information to obtain this benefit can be punished by law, including

fines, imprisonment, de-enrollment or being barred from the program

Signature: _________________________________________ Date: ________________

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

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