Form 201tel - Application For The Lifeline Program

Statement of Agreement

You must initial each statement below — in the box provided — to certify your agreement.

Initial each box

…

I meet the eligibility critera for getting Lifeline— based on either household income or

public benefits —as described on page one of this application.

…

I understand that providing false or fraudulent information to get a Lifeline benefit is

punishable by law and certify that the information in this application is true, correct

and complete to the best of my knowledge.

…

I understand that only one Lifeline benefit is allowed per household and certify that,

to the best of my knowledge, no one else in my household is getting a Lifeline discount

from any provider.

…

I understand that I may not transfer my Lifeline benefit to any other person, whether

they are eligible or not.

…

I understand that I will be required to re-certify my continued eligibility every year or

at any time upon request. Failure to do so will result in termination from the program.

…

I will notify my service provider within 30 days if I move to a new address or there are

any changes that could affect my eligibility for Lifeline (e.g., more than one Lifeline

benefit in the household or changes to household income, public benefits or members).

Certification

I certify that, to the best of my knowledge, I:

 Do  Don’t - live at an address occupied by multiple households.

 Do  Don’t - share an address with other adults who do not contribute income to my

household and/or share in the household’s expenses.

Applicant’s Declaration & Signature

You MUST sign below. Unsigned applications will be returned for signature.

If prepared by a person other than the applicant, this declaration further provides that under 32 V.S.A.

§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.

____________________________

________

_______________________________________

Print Account Holder’s Name

Account Holder’s Signature

Date

_______________________________________

____________________________

_________

Print Preparer’s Name (if not account holder)

Preparer’s Signature

Date

MAIL YOUR SIGNED APPLICATION & ANY REQUIRED SUPPORTING DOCUMENT TO:

THE LIFELINE PROGRAM - ADPC, 280 STATE DRIVE, WATERBURY, VT 05671-1500

Form 201tel - Application For The Lifeline Program - 2017 Page 2

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