Nebraska Telephone Assistance Program (Ntap) Application And Certification Form printable pdf download

Nebraska Telephone Assistance Program (Ntap) Application And Certification Form

NEBRASKA TELEPHONE ASSISTANCE PROGRAM (NTAP)/LIFELINE

APPLICATION AND CERTIFICATION FORM

7-2017

(If you live on Tribal land,

DO NOT

use this application. Contact your local company for a Tribal land discount.)

For eligible Nebraskans, this program, administered by the Nebraska Public Service Commission, reduces the cost of service by

up to $12.75 per month or provides minutes to an eligible cellular service. Some companies are not eligible to participate in this

program. If you are unsure of your companies’ participation, please see the enclosed list.

(Fronts and Backs).

APPLICANT INSTRUCTIONS:

PLEASE PRINT CLEARLY. Read this application completely

order to be approved for assistance you must complete and sign this application. ALL AREAS NEED TO BE COMPLETED.

Provide all documents requested, sign this application and return it to the NTAP department at: PO Box 94927, Lincoln, NE

Completion of this application does not guarantee approval. After your application is

68509.

reviewed; further documents may be required.

Have Questions: Call 1-800-526-0017 or in Lincoln, 402-471-3101

United States Citizenship Attestation: For the purpose of complying with Neb. Rev. Stat. §§ 4-108

through 4-114, I attest as follows (Please select one):



I am a citizen of the United States

----OR ----



I am a qualified alien under the federal immigration and Nationality Act, my immigration status and alien number are as

follows: My alien number is: ___________________________ and I agree to provide a copy of my USCIS documentation

upon request.

Members of the Applicant’s Household

A “household” is any individual or group of individuals (related or unrelated) who are living together at the same

address as one economic unit. If an adult has no or minimal income and lives with someone who provides financial

support to him/her, both people shall be considered part of the same household. Children under the age of eighteen

living with their parents or guardians are considered to be part of the same household as their parents/guardians.

Please list requested information for applicant and all members of your

household below.

First Name

Last Name

Complete Social Security

Date of Birth

Number

(Month/Day/Year)

****PLEASE NOTE: THIS APPLICATION IS PRINTED FRONT AND BACK. REMEMBER TO

DOUBLE CHECK EACH SIDE TO MAKE SURE YOUR APPLICATION IS COMPLETE****

Nebraska Telephone Assistance Program (Ntap) Application And Certification Form