Lifeline Assistance Application And Certification Form - South Dakota Public Utilities Commission
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1
2Lifeline Assistance Application and Certification Form
(Please Print or Type)
Company Name _________________________________________________________ SPIN ________________
Last Name:_______________________________ First Name:________________________ Middle Initial:______
Residential Address:______________________________ City:_________________ State:_______ ZIP:________
(Do not use a P.O. Box address.)
Is your residential address a permanent address?
Yes ______ No ______
Billing Address:_________________________________ City:__________________ State:_______ ZIP:________
(If different from residential address.)
Social Security Number (last four digits):__________________________ (If you are a member of a Tribal nation and do
not have a social security number, you may provide your Tribal identification number.)
Date of Birth:____________________
Telephone Number:___________________________ (if existing service)
Telephone number where you can be reached or receive messages:____________________________
Are you currently receiving Lifeline assistance through any other telephone provider?
Yes _____ No _____
I am applying for:
_____Lifeline (monthly telephone service discount)
_____Toll Limitation Service (free toll blocking or toll control)
I, one or more of my dependants, or my household currently participates in one or more of the following programs: Check
all that apply and provide documentation of proof.)
_____ Medicaid (e.g. Title XIX/Medical State Supplemental Assistance)
_____ Supplemental Nutrition Assistance Program (SNAP, formerly known as Food Stamps)
_____ Supplemental Security Income (SSI)
_____ Federal Public Housing Assistance (Section 8)
_____ Low-Income Energy Home Assistance Program (LIHEAP)
_____ Temporary Assistance for Needy Families (TANF)
_____ National School Lunch Program’s Free Lunch Program
_____ OR my household income is at or below 135% of the Federal Poverty Guidelines. The number of individuals in
my household is:___________.
If you do not participate in one or more of the programs listed above, you may qualify for Lifeline if your household
income does not exceed 135% of the Federal Poverty Guidelines (see table below).
2012 Health and Human Services Poverty Guidelines
Number in
135% Guideline (Annual)
Number in
135% Guideline (Annual)
Residence
Residence
1
$15,080
5
$36,464
2
$20,426
6
$41,810
3
$25,772
7
$47,156
4
$31,118
8
$52,502
For each additional person after 8, add $5,346 to the annual guideline.
Source: Federal Register, Vol. 77 No. 17, January 26, 2012, pp. 4034-4035
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