Pa Lifeline Application printable pdf download

Pennsylvania Lifeline Program Application

Lifeline is a federal program that helps qualified individuals pay for telephone service. It helps customers who have incomes at or below 135 percent

of the federal poverty guidelines or receive help from any of the participating programs below.

The Lifeline program helps reduce the cost of basic monthly phone service for one telephone line. Customers who receive Lifeline assistance may

also purchase optional services such as High Speed Internet or Caller ID at the normal cost.

INSTRUCTIONS

1. Complete Section A. (required) 2. If you are applying based on Program Participation, complete Section B. (if applicable)

3. If you are applying based on Household Income, complete Sections C and D. 4. Complete Section E. (required)

Information

Applicant

The applicant must NOT be a dependent for federal income tax purposes unless he or she is 60 years of age or older.

Name: Last

First

M.I.

Current Home Telephone Number:

Residence Street Address (No P.O. Box, Must be your principal address):

Apt/Floor/Other

City

State

Zip

This address is

Permanent

Temporary

Multi-Household at same address

(complete Household Worksheet.)

Billing Address: (if different from street address)

Date of Birth:

Social Security Number (last 4 digits only)

How many people reside in your household? ______

No. of Dependents (including self) ______

Do you currently receive Lifeline credit with another phone service provider (including wireless)?

Yes

If yes, enter Telephone number ___________________and current provider__________________________________

If yes, do you authorize Windstream to transfer your benefit to the home telephone number above?

Yes

B. Eligibility Based on Program Participation

If you participate in one of the following programs, you are eligible for Lifeline – please put an “X” by the program(s) that apply to you and

provide a copy of the applicable support. (If you select a program proceed to Section E).

___ Federal Public Housing Assistance/Section 8

___ Temporary Assistance for Needy Families (TANF)

___ Supplemental Security Income (SSI)

___ Low-Income Home Energy Assistance Program (LIHEAP)

___ Medicaid

___National School Free Lunch Program

___ Supplemental Nutrition Assistance

Program (SNAP), formerly Food Stamps

C. Eligibility Based on Household Income

If you do not participate in one of the programs listed under “B” above, you may qualify based on HOUSEHOLD Income. The below lists the

annual income amount that cannot be exceeded in order to qualify based on family size. 2015 135% Federal Poverty Guideline (annual

household Income Before Taxes) 1 person up to $15,890; 2 people up to $21,506; 3 people up to $27,122; 4 people up to $32,738. For each

additional person, add $5,616.

Please provide proof of all income for you and anyone in your home that is not a dependent. Such proof may include but is not limited to W2,

Paycheck Stubs; prior year state or federal tax returns, etc. If you are enrolling based on income, you must complete Section D below.

D. ADDITIONAL MEMBER OF HOUSEHOLD

If you qualified based on Section C, you must complete the following information as well.

Is there anyone living in the home that is not a dependent of the applicant?

YES

(If No, proceed to Section E)

August, 2015

Pa Lifeline Application

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