Lifeline Application - Virginia T-Mobile (Page 2 of 2) in pdf

Lifeline Application (continued)

First Name: _________________________MI: ________Last Name: ______________________Date of Birth: _____/______/______

Last 4 Digits of Social Security Number: _________ T-Mobile Number: __________________________________________________

CERTIFICATION

I certify, under penalty of perjury, that:

Initial by Each Certification

_____

The information provided in this Application is true and correct to the best of my knowledge; I acknowledge that willfully

providing false or fraudulent information in order to receive Lifeline service is punishable by fine or imprisonment,

termination of all Lifeline benefits, and being barred from participating in the Lifeline program.

_____

I am eligible for Lifeline service through participation in the qualifying program(s) or meeting the income requirements as

identified above.

_____

I have provided documentation of eligibility for Lifeline service, unless otherwise specifically exempted from providing such

documentation, and the documentation I have provided demonstrates my eligibility. If I’ve provided income

documentation other than a prior year’s state or federal tax return, I’ve submitted three consecutive months worth of the

same type of document within the current calendar year. I understand that submitted documents will not be returned.

_____

I understand that I am required to inform T-Mobile within 30 days of any potential change in eligibility, including, but not

limited to: (i) a move or change of address; (ii) any change in participation in the programs identified above or change in

income or Household members; (iii) receiving Lifeline service from another provider; or (iv) any other change that would

affect my eligibility for Lifeline service from T-Mobile; and that any failure to do so may result in penalties including loss of

Lifeline benefits (among other things).

_____

I have provided the address where I currently reside and, if a temporary address has been provided, then I acknowledge

that T-Mobile may attempt to verify my address every 90 days, and, if I do not respond to verification attempts within 30

days, then my Lifeline service may be terminated.

_____

My Household will receive only one Lifeline benefit and, to the best of my knowledge, no one in my Household is currently

receiving Lifeline service from any other provider, wireline or wireless, postpaid, prepaid or free, including SafeLink or

Assurance Wireless.

_____

I acknowledge that I will be required to annually re-certify eligibility and may be required to re-certify continued eligibility

for Lifeline at any time and failure to re-certify will result in the termination of Lifeline benefits or other penalties.

_____

I authorize T-Mobile and its agents to access any records (including financial records) required to verify my statements

herein and to confirm my eligibility for Lifeline service. I authorize government agencies and their authorized

representatives to discuss with, receive from and provide information to T-Mobile and its agents verifying my participation

in public assistance programs that qualify me for Lifeline service.

_____

I acknowledge that T-Mobile may, and I give my consent for T-Mobile to, provide my personal information, including my

name, address, and telephone number among other items as required, to the Universal Service Administrative Company for

the purposes of verifying that neither I, nor anyone else in my Household, receive more than one Lifeline benefit and other

purposes allowed by law.

: ____________________________________

: ______________________________________

PPLICANT

IGNATURE

ATE

SUBMISSION INSTRUCTIONS

THIS FORM MUST BE COMPLETED IN ITS ENTIRETY AND CAN BE SUBMITTED BY:

MAIL

FAX

T-M

– L

813-348-5724

OBILE

IFELINE

UPPORT

P.O. B

37380

, N

87176

IF YOU HAVE QUESTIONS, PLEASE CALL 1-800-937-8997 FOR ASSISTANCE.

LBUQUERQUE

EXICO

NOTICES

T-Mobile offers Lifeline services only in areas where it has been designated as an Eligible Telecommunications Carrier.

FOR OFFICE USE ONLY

Representative: _______________________________ Signature: __________________________ Date: ______________________

Documentation Verified: _____________________________________ BAN: ____________________________________________

Subscriber No: _____________________________________________

VA1602TMO

Lifeline Application - Virginia T-Mobile Page 2

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