Nebraska Telephone Assistance Program (Ntap) Application And Certification Form (Page 2 of 4) in pdf

Nebraska Telephone Assistance Program (NTAP) Applicant Information-Please Print

Applicant Name: Last __________________________________ First _____________________________________ MI_______

Last 4 digits of Applicant’s Social Security Number: ___________________ Applicant’s Date of Birth: _____/______/_______

Complete Street Address of where you live

(This cannot be a PO Box and must be the address listed or will be listed with your company):

Street Address: ______________________________________________________________

Apt-Room-Lot Number: ________________

City: __________________________________

State: ___________

Zip Code: __________________

☐ Temporary ☐ Permanent

Please check one: Is the address listed above:

Mailing Address:

ONLY

if different from the address you listed above. This

can be

a PO Box.

Mailing Address: ___________________________________________________________________________________________

City: __________________________________________

State: _________

Zip: _____________

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.

How many people live in your household, including applicant ________________

(this needs to be a number greater than zero).

Please read definition of household above. Household does not include others living at apartment complex, nursing home

or assisted living building, only those at your specific address.

☐ NO or ☐ YES

Is there more than one household at the address you listed above? Check

Account INFORMATION ***PLEASE NOTE*** Not all companies participate with NTAP or provide NTAP in all coverage areas. For

participating companies please see list, if included, or contact the NTAP department.

**If you are applying for a free phone and minutes,

you will need to contact the phone company, set up an account and obtain your reserved phone number.** Also, you must use the phone at

least once every thirty (30) days or your phone will be disconnected and you will need to

reapply.***NOT ALL ACCOUNTS QUALIFY***

If you currently have phone service please complete the information below:

Name of My Company: __________________________________________________________________

My Phone Number is: (______) ___________________________________________________________

Customer Name on Account/ Bill: _______________________

______________________________________

The account must be in/contain the applicant’s name

If you don’t currently have phone service and are checking if you’re eligible, mark

I Do Not currently have phone service: __________

If you don’t currently have phone service, but know what service provider you want: Make sure the phone company

participates. Next, you will need to contact the company you wish to have service with and set up an account.

Then do the following:

1. Set up your account with the phone company and obtain your phone number.

2. Complete information requested below.

Name of My Company: _________________________________________________________________

My Phone Number is: (______) __________________________________________________________

Customer Name on Account/ Bill: _________________________________________________________

Nebraska Telephone Assistance Program (Ntap) Application And Certification Form Page 2

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