Form 201tel - Application For The Lifeline Program - 2017
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1
22017 Application for the Lifeline Program
201TEL
Revised 1/2017
Name of the service provider
Service you’re applying for (select only one):
Phone
OR
Internet
(wireless or landline)
(home or mobile data)
Name of account holder (person on bill)
Date of birth (mm/dd/yyyy)
Social Security Number
Name of account holder’s spouse or partner
Date of birth (mm/dd/yyyy)
Social Security Number
Is this your permanent address?
Physical address (street, house number, town, state, & zip code)
Yes
No
Billing address if different (PO box/street & house number, town, state, & zip code)
Home phone (with area code)
Email address (optional)
Number of people in your home:
Is this your first Lifeline application?
Yes
No
HOUSEHOLD BENEFITS OR INCOME
Complete Section A or Section B, not both.
Section A: Public Benefits - Doesanyoneinyourhouseholdgetpublicbenefits?
Yes No
Ö
If you answered NO, skip to Section B
Ö
If you answered YES:
•
Check at least one of the benefits listed below
•
Send proof of participation for one of the benefits checked (
)
If a supportIng document Is requIred
•
If required, make sure the supporting document is dated within the past 60 days of the date of your
application and send a copy as originals will not be returned
PUBLIC BENEFITS
PROOF OF PARTICIPATION / SUPPORTING DOCUMENT REQUIRED
3SquaresVT
No supporting document required
Fuel Assistance
Reach Up
Federal Public Housing Assistance
Letter confirming benefits - VSHA: (802) 828-3295
Letter confirming benefits - Green Mountain Care: 1-800-250-8427
Medicaid
Letter confirming benefits - Social Security: 1-800-772-1213
Supplemental Security Income (SSI)
Veterans Pension / Survivors Pension Letter confirming benefits - Veteran’s Affairs: 1-800-827-1000
Section B: Household Income
If you complete this section, you must include proof of your household income for the 2016 taxation year
(e.g., last year’s federal income tax return).
Total household income:
$
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