Lifeline Household Worksheet

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United Utilities United-KUC Yukon Telephone
Lifeline Household Worksheet
PO Box 92730, Anchorage, AK 99509
1-800-478-2020 Fax: (907)273-5322
Lifeline Phone/Account Number: (907) ___________________________ Customer Name: ____________________________________________________
Physical Address: _________________________________________________________________________________________________________________
Street Address (Not PO Box), Location Description, or Demark-NID-Protector#
City
State
ZIP
This Worksheet must be completed and submitted with your Lifeline application.
Important Legal Notice:
Lifeline is a government program that provides a monthly discount on home, mobile or broadband internet services. Only ONE Lifeline discount is allowed per household. Members of a
household are not permitted to receive Lifeline service from one or more telephone companies. Willfully making false statements to obtain the benefit can result in fines, imprisonment, de-
enrollment, or, being barred from the program.
Definition of Household for Lifeline Purposes: Your household is everyone who lives together at your address as one economic unit (including children and people who are not related to
you). The adults you live with are part of your economic unit if they contribute to and share in the income and expenses of the household.
An adult is any person 18 years of age or older, or an emancipated minor (a person under age 18 who is legally considered to be an adult). All adults living together and contributing to and
sharing in the income or expenses of the household, whether spouses, domestic partners related or unrelated, are part of the same household. Household expenses include food, health
care expenses (such as medical bills), and the cost of renting or paying a mortgage on your place of residence (a house or apartment, for example) and utilities (including water, heat and
electricity). Income includes salary, public assistance benefits, social security payments, pensions, unemployment compensation, veteran’s benefits, inheritances, alimony, child support
payments, worker’s compensation benefits, gifts, Alaska PFD, and lottery winnings.
Spouses and domestic partners are considered to be part of the same household. Children under the age of 18 living with their parents or guardians are considered to be part of the
same household as their parents or guardians. If an adult has no income, or minimal income, and lives with someone who provides financial support to that adult, both people are
considered part of the same household.
Other Lifeline Service:
Do you have Lifeline Service with another telephone provider?
Yes
No
If you checked Yes, you are ineligible for Lifeline because a household may not receive Lifeline benefits from multiple providers. Please sign, date and
return this worksheet. If you checked No, please continue to the next section.
Household Information:
1. Does your spouse, domestic partner (that is, someone you are married to or in a relationship with), or anyone else in your household already receive a
Lifeline discounted phone?
Yes
No
If you checked Yes, you are ineligible for Lifeline because someone
If you checked No, please answer question #2.
in your household already receives Lifeline. Only ONE Lifeline discount
is allowed per household. Please sign, date and return this worksheet.
2. Do other adults (people over the age of 18 or emancipated minors) live with you at your home address? Other adults may include parents, adult children,
siblings, aunts or uncles, or adult roommates.
Yes
No
If you checked Yes, please answer question #3
If you checked No, you do not need to answer the remaining questions. Please
Initial Line B in the certification section, and sign, date and return this worksheet.
3. Do you share living expenses (bills, food, etc.) and share income (your income, the other person’s income or both incomes together) with at least one of
the adults referenced in question #2?
Yes
No
If you checked Yes, then you share a household. Please
If you checked No, then your address includes more than one household. Please
provide identifying information below for any adults for whom
initial Lines A and B below, and sign, date and return this worksheet.
you checked yes. You may not sign up for Lifeline if another adult
in your household already receives Lifeline
4. Please list the name, birth date or year of birth (if known) and last four digits of the Social Security Number (if known) for any adult at your home address
with whom you share living expenses and income. If you need more room, please write on the back of this form.
Name
Birth Date
Last 4 of Social Security #
Name
Birth Date
Last 4 of Social Security #
Certification:
Please initial the certifications below if applicable (see above); sign and date this worksheet; and return to United Utilities/United-KUC/Yukon Telephone,
along with your Lifeline Application.
A.
I certify that I live at an address occupied by multiple households.
______(initial)
B.
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.
_______(initial)
BY SIGNING BELOW, I CERTIFY ALL THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE SUBJECT TO THE PENALTY OF PERJURY.
_______________________________________________________________________________________
_________________________
CUSTOMER SIGNATURE
DATE
Household Worksheet (12-2016) Page 1 of 1
United CSR:______________________________________________

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