Membership Application Form Page 2
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3EXHIBIT “A” to Lifeline Eligibility Verification Policy
You may qualify for Lifeline either because (A) you participate in a qualifying government PROGRAM OR (B) your total annual household
income is within INCOME guidelines (next page). Please complete at least one eligibility method: Section (A) or (B).
(1)
Program Based Eligibility
I certify that I, or a member of my household, participate in at least one of the
If you live on a tribal land/reservation (as defined in
following programs (please check at least one):
the Code of Federal Regulations at Title 47, Section
54.400(e)), you may also qualify for Lifeline if you
participate in one of these additional qualifying
programs (please check at least one):
Medicaid
Supplemental Nutrition Assistance Program (SNAP)
Bureau of Indian Affairs General
Assistance
Supplemental Security Income (SSI)
Food Distribution on Indian
Federal Public Housing Assistance (Section 8)
Reservations (FDPIR)
Veterans and Survivors Pension Benefit
Tribally Administered Temporary
Assistance for Needy Families
(TANF)
Head Start (must meet income-
qualifying standard)
(2)
Income Based Eligibility
Total number of
persons in my household: __________
Total annual household income: ________________________
By my initials and by signing this application, I certify that my total household
income is at or below 135% of the Federal Poverty Guidelines (See 2015
FEDERAL POVERTY GUIDELINES).
Applicant Initials: __________
(C)
PROOF OF ELIGIBILITY
PHOTOCOPY (original documentation will NOT be returned) one or more of the following acceptable proofs of your eligibility and submit
with this application.
(1)
Program Based Eligibility
If applicable, attach copies of one or more of the documents listed below:
The current or prior year’s statement of benefits from the program(s) marked in Section (A)
A notice letter of participation in the program(s) marked in Section (A)
A program participation document from the program(s) marked in Section (A)
Other official document proving participation in the program(s) marked in Section (A)
Benefit Qualifying Person (Provide information below only if name is different from Applicant)
Full Name: ___________________________________________________________
Benefit Recipient’s Date of Birth: _____/_____/__________
Last 4 digits of Social Security Number: ______________________
Tribal ID (if applicable): __________________________________
CONTINUED ON NEXT PAGE.
(C) PROOF OF ELIGIBILITY
(continued)
(2)
Income Based Eligibility
Page 2 of 3
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