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EXHIBIT “A” to Lifeline Eligibility Verification Policy
NORTHEAST RURAL SERVICES, INC. D/B/A BOLT FIBER OPTIC SERVICES
LIFELINE ASSISTANCE APPLICATION
THIS SIGNED APPLICATION IS REQUIRED IN ORDER TO ENROLL YOU IN THE LIFELINE PROGRAM AS APPROVED BY THE FEDERAL
COMMUNICATIONS COMMISSION (FCC). THE FORM IS ONLY FOR THE PURPOSE OF CERTIFYING YOUR ELIGIBILITY FOR THE LIFELINE OR
TRIBAL LINK UP PROGRAM AND WILL NOT BE USED FOR ANY OTHER PURPOSE. PLEASE PRINT USING BLOCK CAPITAL LETTERS IN
BLACK OR BLUE INK ONLY. WHEN COMPLETED, PLEASE MAIL THE FORM AND COPIES OF PROOF OF ELIGIBILITY TO: P.O. BOX 399,
VINITA, OK 74301 ATTN: SHEILA ALLGOOD
(A)
APPLICANT INFORMATION
Full Name:
Residential Address:
Line 1:
City:
State:
ZIP Code:
Is this a Temporary
Date of Birth:
Address (Y/N):
Last Four Digits
Tribal ID (if applicable):
of Social Security
Number:
Billing Address (if different from Residential Address):
Line 1:
City:
State:
ZIP Code:
IMPORTANT DISCLOSURES
Lifeline is a government benefit that helps eligible consumers pay for telephone services by discounting their monthly service bill.
Willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the
program.
Only one Lifeline service benefit is available per household. A subscriber must be verified by the FCC National Lifeline
Accountability Database (NLAD) before he/she can be enrolled in Lifeline.
A household is defined, for purposes of the Lifeline program, as any individual or group of individuals who live together at the same
address and share income and expenses.
A household is not permitted to receive Lifeline benefits from multiple providers.
Violation of the one-per-household limitation constitutes a violation of FCC rules and will result in the subscriber’s de-enrollment
from the program.
Lifeline is a non-transferable benefit and the subscriber may not transfer his or her benefit to any other person.
Please complete the Lifeline Household Worksheet attached and submit the completed Worksheet with this Application.
National Lifeline Accountability Database (NLAD) Disclosure and Consent
The FCC has ordered the creation of a National Lifeline Accountability Database. Northeast Rural Services, Inc., d/b/a BOLT Fiber Optic
Services (BOLT) must provide the following information to the database in order to ensure the proper administration of the Lifeline
Program:
Your full name
Your full residential address
The date BOLT began providing
you with Lifeline service
Your date of birth
The amount of the discount BOLT
The Future date when your
provides
Lifeline service with BOLT ends
Your telephone number
Whether your eligibility is program or
The last four digits of your Social
income based
Security Number (or Tribal ID)
By my initials and by signing this application, I confirm I have read and understand the disclosures provided above and hereby consents
to BOLT’s release of any of my information contained in this Lifeline Application required for the administration of the Lifeline program to
the FCC or its designee, including the Universal Service Administrative Company, and to any state and federal agency or its designee, as
required by law. (Failure to provide consent will result in being denied Lifeline service.)
Applicant’s Initials: _______
CONTINUED ON NEXT PAGE
(B) ELIGIBILITY REQUIREMENTS
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