Application For Lifeline Telephone Service Credit - Vermont

2013 Application for Lifeline Telephone Service Credit

201TEL

You may be eligible for a credit of at least $9.25 toward the payment of

your monthly Vermont basic telephone charge. To apply, return this

form by June 15, 2014.

You must reapply for the credit each year.

Are you a Vermont resident?

Will you be at least 65 by June 15, 2014?

Will you be younger than 65 on June 15, 2014?

Was your 2013 household income (for definition of “income” and

“household”, see instructions) less than $27,142.50 (from Income

“household”, see instructions) less than $23,265.00 (from Income

section below, Line p) OR are you eligible for participation in any of

the public benefit programs listed in the instructions section?

If you answer “Yes” to all questions, you may be eligible

The following section must be filled out completely or your application will be returned and benefits will be delayed

Your Name _______________________________________ Spouse or CU Partner Name ________________________________________

Name on Phone Bill ________________________________ Name of your telephone company ___________________________________

Street Address ____________________________________ Billing Address ___________________________________________________

Address permanent or temporary _____________________________ Telephone Number _____________________________________

City_______________________________ State _____________ Zip Code ___________________ Number of people in household _____

Social Security Number, Applicant _______________________________ Spouse or CU Partner __________________________________

Date of Birth, Applicant (MM/DD/YYYY) ___________________________ Spouse or CU Partner __________________________________

INCOME (Total household income)

Cash public assistance/welfare ......................................................................................... a._________________________

Social Security/railroad retirement/veterans’ benefits, taxable and nontaxable .................... b._________________________

Unemployment compensation/worker’s compensation .......................................................... c._________________________

Wages, salaries, tips, etc. ................................................................................................ d._________________________

Interest and dividends ..................................................................................................... e._________________________

Interest on U.S., state and municipal obligations, taxable and nontaxable ........................... f._________________________

Alimony, support money/child support ............................................................................... g._________________________

Business Income: If you have a loss, enter –0- ............................................................... h._________________________

Capital gains, taxable and nontaxable ................................................................................. i._________________________

Pensions and annuities, taxable and nontaxable ............................................................... j._________________________

Rental income: If you have a loss, enter –0- .................................................................. k._________________________

Farm/partnership/Subchapter S income: If you have a loss, enter –0- ................................ l._________________________

m. Other income. Please specify ........................................................................................... m._________________________

SUBTOTAL: Add Lines a through m.................................................................................... n._________________________

LESS adjustments to income from Federal Form 1040, Line 36 or 1040A, Line 20.................... o._________________________

TOTAL INCOME: Subtract Line 0 from Line n and enter the result here ................................ p._________________________

I declare under penalty of perjury this application is true, correct, and complete to the best of my knowledge and acknowledge that providing false or fraudulent information to

receive Lifeline benefits is punishable by law. 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 con-

sent form is signed by the applicant and retained by the preparer. I authorize the VT 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

____________________________________________________________

Spouse or Civil Union Partner signature (if filing jointly)

Date

Address of preparer