Pa Lifeline Application (Page 2 of 2) in pdf

If Yes, please print the name below and provide proof of income as stated in Section C.

Name: Last

First

M.I.

Relationship to Applicant

E. PLEASE READ THE FOLLOWING PROGRAM RULES AND SIGN

Windstream is required by the Federal Communications Commission, or FCC, to verify your eligibility to participate in the Lifeline discount

program and to advise you that willfully making false statements can result in fines, imprisonment, de-enrollment or being barred from the program.

Only one Lifeline discount is allowed per household, consisting of either wireline or wireless service. A household is defined as any individual or

group of individuals who are living together at the same address as one economic unit. An economic unit consists of all adult individuals

contributing to and sharing in the income and expense of a household.

To qualify for the Lifeline discount program you must under penalty of perjury certify the following statements are true and agree to abide

by the program’s rules.

(1) I certify that the household in which I reside is not currently receiving a Lifeline discount from any other providers.

(2) I agree that the Lifeline service is a nontransferable benefit and may not be transferred to anyone, including another eligible

low-income consumer.

(3) I agree to notify Windstream within 30 calendar days if I move to another address and provide the new address.

(4) I agree to notify Windstream within 30 calendar days if I am no longer, for any reason, receiving benefits from the federal or

state program which qualified me for the Lifeline discount program, if my household income exceeds 135% of the Federal

Poverty Guidelines, if I am receiving more than one Lifeline service, or if I no longer satisfy the criteria for receiving Lifeline

support and I am subject to penalties if I fail to do.

(5) I agree to participate in the certification of my continued eligibility in the Lifeline discount program on an annual basis.

(6) I agree to allow Windstream to provide the subscribers name, telephone number, and address to Universal Service

Administrative Co (USAC) to verify my eligibility to participate in the Lifeline discount program.

(7) I certify that I am an eligible resident of a Tribal Land

I hereby certify under penalty of perjury that the information provided on this application is true and correct and reflects my current status of program

participation or an accurate statement of HOUSEHOLD Income.

______________________________________

______________

Signature of Applicant

Date

Return Completed Application and Proof Documents to:

For Official Use Only

Windstream Communications

ATTN: Support Services-Lifeline

Eligibility Form Reviewed: ________________

1720 Galleria Boulevard

Charlotte, North Carolina 28270

Reviewed By: ___________________________

FAX: (704) 849-7000

OR Email to

Representative Signature: __________________

Any questions, please contact Windstream at 1-800-347-1991

Date: _________________

August, 2015

Pa Lifeline Application Page 2

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