Form Application For Lifeline Telephone Service Credit - Vermont - Draft - 2009

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DRAFT - 24 NOV 2009
L
Application for Lifeline
IFELINE
2009 VERMONT
Telephone Service Credit
You may be eligible for a credit of at least $13.00 toward payment of your monthly Vermont basic telephone
charge. To apply, return this form by June 15, 2010. You must reapply for the credit each year.
If you will be 65 or OLDER by June 15, 2010.
If you will be UNDER 65 on June 15, 2010.
OR
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 younger than 65 on June 15, 2010?
Yes
No
Will you be at least 65 by June 15, 2010?
Yes
No
Was your 2009 household income for you and your spouse less than
Was your2009 household income for you and your spouse less than
$21,855 (from Income section below, Line p.)?
Yes
No
$25,498 (from Income section below, Line p.)?
Yes
No
If you answer “Yes” to all questions, you are eligible.
If you answer “Yes” to all questions, you are 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 _____________________________________
Telephone Number
Street, P .O. Box or RD _____________________________________________________________
City ___________________________________ State______ Zip Code ____________________
Social Security Number
Birthdate
Sex
Month
Day
Year
F/M
Yours
Yours
Spouse or
Spouse or
CU Partner
CU Partner
INCOME (Total, You and Spouse or CU Partner combined)
a. Cash public assistance/welfare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a. ___________________
b. Social Security/railroad retirement/veteran’s benefits, taxable and nontaxable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. ___________________
c. Unemployment compensation/worker’s compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c. ___________________
d. Wages, salaries, tips, etc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. ___________________
e. Interest and dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e. ___________________
f. Interest on U.S., state and municipal obligations, taxable and nontaxable. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . f. ___________________
g. Alimony, support money/child support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g. ___________________
h. Business income: If you have a loss, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . h. ___________________
i. Capital gains, taxable and nontaxable. If you have a loss, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i. ___________________
j. Pensions and annuities, taxable and nontaxable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . j. ___________________
k. Rental income: If you have a loss, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . k. ___________________
l. Farm/partnership/Subchapter S income: If you have a loss, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l. ___________________
m. Other income. Please specify___________________________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . m. ___________________
n. SUBTOTAL: Add lines a through m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n. ___________________
o. LESS adjustments to income from Federal Form 1040, Line 36 or 1040A, Line 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o. ___________________
p. TOTAL INCOME: Subtract Line o from Line n and enter the result here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p. ___________________
O
U
O
NR
FFICIAL
SE
NLY
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 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. 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
41
* See back for help finding your Company Code.

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