Fillable Membership Application Form (Page 3 of 3) in pdf

EXHIBIT “A” to Lifeline Eligibility Verification Policy

If applicable, attach copies of one or more of the documents listed below:

• Prior year’s federal, state or tribal Tax

• Social Security statement of benefits

• Retirement/Pension statement of benefits

return

• Paycheck stubs for most recent three

• Other official document containing income

• Unemployment/Workmen’s

(3) months

information

Compensation statement of benefits

• Divorce Decree/Child Support

• Federal or Tribal General Assistance Notice

• Current income statement from

document

Letter

employer

• Veteran’s Administration benefits

statement

SIGNATURE AND CERTIFICATION

By signing below, I certify, under penalty of perjury, that:



The information contained in this application is true and correct to the best of my knowledge.



I meet the program or income based eligibility criteria for receiving Lifeline benefits.



The telephone service for which I am requesting Lifeline is in my name and, to the best of my knowledge, this Lifeline

telephone account will represent the only Lifeline telephone service provided to my household, and I am aware that I can only

receive the Lifeline telephone discount on one phone line (wireline or wireless).



(Only if applicable) If the address above is a temporary address, I may be required to verify my temporary address every 90

days.



If I move to another address, I will provide notice of that address to my carrier within 30 days.



I acknowledge that providing false or fraudulent documentation in order to receive Lifeline benefits is punishable by law.



I acknowledge that I may be required to re-certify my continued eligibility for Lifeline assistance at any time and that failure to

do so will result in de-enrollment and termination of Lifeline benefit.



I understand that if I fail to re-certify my eligibility and I am de-enrolled, I will be required to pay the full published monthly

recurring charges for my telephone service going forward.



If in the future I, or the qualifying member of my household, no longer participate in at least one of the federally qualifying

programs or my total household income exceeds 135% of the Federal Poverty Guidelines listed in Section (B), I begin

receiving benefits from another carrier, or if conditions above change, I will promptly notify my carrier within thirty (30) days

that I am no longer eligible for Lifeline assistance. Annually, I will need to re-certify my participation in the Lifeline program.

I affirm under penalty of perjury, that the foregoing representations are true. This application will not be processed without a signature,

date of birth and last 4 digits of Social Security Number (or Tribal ID, if applicable).

Applicant’s Signature: ____________________________________________

Date: _____/_____/__________

Last 4 Digits of

Social Security

Tribal ID

Applicant’s Date of Birth: _____/_____/__________

Number:

______________

(if applicable): ______________

Page 3 of 3

Membership Application Form Page 3

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