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

CERTIFICATION STATEMENTS:

Each of the statements MUST be INITIALED in order to receive

assistance.

By reading and marking each statement I Certify Under Penalty of Perjury and understand that

failure to comply with the statements below will result in removal of credits provided on my account, loss of

minutes or termination of your service.

_____:

Initial

I understand that I will not be able to transfer my NTAP benefit to another provider for 60 days if I have voice

service, or 12 months if I have broadband service unless, I move, my provider is no longer in service, my provider fails to provide

service, my provider has imposed late fees for non-payment on the service greater than or equal to the monthly charge for

service or my provider is found in violation of Commission rules for the benefit year and I am impacted by the violation.

_____:

Initial

I agree to complete a new application, notify my provider and NTAP within 30 days of moving.

_____:

Initial

I understand completion of this application does not constitute immediate acceptance into this program.

_____:

Initial

I understand that I will be required to recertify my information and provide proof of participation in one of the programs listed

in the eligibility section of this application or provide proof that my income is currently at or below 135% of the poverty level at any time.

I understand that failure to recertify my information and/or provide proof of current participation in one of the programs listed in the eligibility

section of this application or that my income is currently at or below 135% of the poverty level will result in being de-enrolled (having the

credit removed from my account or termination of service) from the program.

_____:

Initial

I understand that NTAP is a non-transferable benefit and that I may not transfer this benefit to any other person.

_____:

Initial

I understand that NTAP is a federal benefit and that willfully making false statements to obtain the benefit can result in

fines, imprisonment, de-enrollment (credit being removed or termination of service) or being barred from the program.

_____:

Initial

I understand that at any time I may be requested to re-certify my continued eligibility and that if I fail to re-certify it

will result in me being de-enrolled (credit removed from my account or termination of service) from the program.

_____:

Initial

I understand that if I am receiving more than one NTAP credit or if for any reason I no longer satisfy the criteria

outlined in this application to receive NTAP support I will notify my company and NTAP within 30 days and that failure to abide

by this requirement may result in penalties or being de-enrolled (credit removed from my account or termination of service) from the program.

_____:

Initial

I understand that there can only be one supported line per household, I have read the definition of household

provided above and I understand that if I violate the one supported line per household rule it violates the FCC’s rules, I will be de-enrolled

(credit removed from my account or termination of service) from the program and this violation could result in criminal prosecution by

the U.S. Government.

_____:

Initial

I will notify my provider and NTAP within 30 days if my household is receiving more than one NTAP benefit or if at

the time that I am applying for NTAP assistance another person in my household is already receiving assistance from the program.

I understand that failure to follow this requirement may result in penalties or being de-enrolled (credit removed from my account

or termination of service).

_____:

Initial

I agree to notify NTAP within 30 days of changing my phone number.

_____:

Initial

I agree to notify NTAP and complete a new application requesting assistance if I decide to change my provider.

_____:

Initial

I understand that if I am completing this application due to a change of providers, it will not result in more than

one NTAP supported account in my household or I understand that in the future if I change providers, this change cannot result in

more than one NTAP supported account in my household.

_____:

Initial

I currently participate in one of the programs listed in the eligibility section of this application or that my income

is currently at or below 135% of the poverty level and I have provided proof of participation or proof of income if required to do so.

_____:

Initial

I understand it is my responsibility to notify NTAP and my provider within 30 days after I no longer participate

in at least one of the qualifying programs or that my income is no longer at or below 135% of the poverty level and that failure to abide

by this requirement may result in penalties or being de-enrolled (credit removed from my account or termination of service).

I hereby certify that my response and the information provided on this form and any related application for public benefits are

true, complete, and accurate and I understand that this information may be used to verify my lawful presence in the United States.

I further certify, under penalty of perjury, the above information is true. I have read the information on this application and

understand I must meet the above qualifications to receive assistance from this program. By signing this application,

I hereby give consent to release my information provided in this application to the administrator of the

Lifeline Program-Universal Service Administrative Company and I understand that the information released will be kept confidential.

Applicant Signature: _____________________________________________________________________________________Date: ___________

**POA Signature: ______________________________________________________________________________

Date: ___________

* If an authorized representative is signing the application, a copy of the Durable Power Of Attorney or Guardianship document must be included

Nebraska Telephone Assistance Program (Ntap) Application And Certification Form Page 4

Related Articles

Related forms

Related Categories