Application For Lifeline Telephone Service Credit - 1998 Vermont

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Lifeline
Application for Lifeline
1998 VERMONT
Telephone Service Credit
SECTION A: Eligibility You may be eligible for a credit of at least $10.50 toward payment of your monthly Ver-
mont basic telephone charge. To apply, complete the following checklist and return this form by June 1, 1999.
You must reapply for the credit each year.
OR
If you will be 65 or OLDER by June 1, 1999.
If you will be UNDER 65 on June 1, 1999.
Complete this checklist to see if you are eligible:
Complete this checklist to see if you are eligible:
Are you a Vermont resident?
Yes
No
Are you a Vermont resident?
Yes
No
Will you be at least 65 by June 1, 1999?
Yes
No
Will you be younger than 65 on June 1, 1999?
Yes
No
Was your 1998 household income for you and your spouse less than
Was your 1998 household income for you and your spouse less than
$18,988 (from Form HI-144, Line s, Columns 1 & 2)?
$16,275 (from Form HI-144, Line s, Columns 1 & 2)?
Yes
No
Yes
No
If you answer “Yes” to all questions, you are eligible.
If you answer “Yes” to all questions, you are eligible.
Customer Code
SECTION B: Identity (please print)
(Bell Atlantic Customers)
Telephone Number
Your Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Your Spouse’s Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Your Social Security Number
Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
City/State/Zip _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
How many people live in your household?_______
SECTION C: INCOME (Total household income for you and your spouse)
Complete Form HI-144 on page 35 and enter the total of Columns 1 & 2, Line s here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $___________________
Attach Form HI-144 if this Lifeline application is being submitted to the Vermont Department of Taxes by itself.
SECTION D: Declaration
I declare under penalties of perjury this application is true, correct, and complete to the best of my knowledge. If prepared by a person other than the appli-
cant, this declaration further provides that under 32 VSA 5901 this information has not been and will not be used for any other purpose, or made available to any other person other than for
the preparation of this application unless a separate valid consent form is signed by the applicant and retained by the preparer. I authorize the Vermont Department of Taxes to disclose this
information and other information necessary to process the Lifeline Credit to the Secretary of Human Services.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Subscriber’s signature
Date
Signature of preparer if other than taxpayer
Date
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Subscriber’s signature
Date
Signature of preparer if other than taxpayer
Date
SECTION E: Information to be sent by the state to your local phone company
(This section MUST be filled out completely. Do not leave blank, even though this repeats information in Section B.)
Customer Code
Your name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(Bell Atlantic Customers)
Telephone Number
(from Section B)
Name on telephone bill _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(if different from your name)
Local phone company _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address on telephone bill _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
City/State/Zip ____________________________________________

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