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Lifeline Service Application and Certification
A complete and signed Lifeline Service Application and Certification is required to enroll you in a Lifeline service program in your state. Service requests will not be processed until this Form has been received and verified. To participate in the program, consumers must either have an income that is at or below 135% of the federal Poverty Guidelines or participate in one of the following assistance programs:


One Lifeline service per household disclosures: Lifeline is a government assistance program and willfully making false statements to obtain a Lifeline benefit can result in fines, imprisonment, de-enrollment or being barred from the program. Lifeline benefits are limited to a single line of service per household. A household is defined, for purposes of the Lifeline program, as any individual or group of individuals who live together at the same address and share income and expenses. A household may not receive multiple Lifeline discounts. You may apply your Lifeline discount to either one landline or one wireless number, but you cannot have the discount on both and you cannot receive Lifeline benefits from multiple providers. Note that not all Lifeline services are currently marketed under the name Lifeline. Lifeline is a non-transferable benefit and you may not transfer your benefit to any other person, including another eligible low-income consumer. Violation of the one-per-household limitation constitutes a violation of the Federal Communications Commission's rules and will result in your de-enrollment from the program, and potentially prosecution by the United States Government. 


No.
Yes. If any member of your household currently receives Lifeline assistance at the above address, you will not be eligible.
Food Stamps (SNAP)
Medicaid
Kids School Free Lunch Program
LIHEAP
SSI
TANF
Public Housing Assistance (Section 8)
Income at or below 135% of Federal Poverty Guideline
I meet the program-based or income-based eligibility criteria for receiving Lifeline service and have provided documentation of eligibility (if required).
Food Distribution Program on Indian Reservations (FDPIR)
Tribally Administered TANF (TATNF)
Head Start (income-eligible only) (Tribal)
Bureau of Indian Affairs (BIA) General Assistance
I hereby certify that the recipient of the above government program lives in my household and does not receive Lifeline.
I hereby certify that I reside at an address occupied by multiple households, who do not contribute income.
I hereby certify that the recipient of the above government program lives in my household.
I will notify my carrier within 30 days if for any reason I no longer satisfy the criteria for receiving Lifeline.
I hereby authorize any records required for the administration of the program, to be used in a eligibility database.
I hereby authorize access to any records required to verify my statements on this form to confirm my eligibility.
I hereby certify that the recipient does not receive Lifeline benefits from any other carrier.
The information contained in this certification form is true and correct to the best of my knowledge.
If I provided a temporary residential address to my carrier, I will verify my temporary residential address every 90 days.
The address listed is my primary residence, not a second home or business.
I acknowledge failure to re-certify within 30 days will result in de-enrollment and termination of my Lifeline benefits.
I acknowledge that I may be required to re-certify my continued eligibility at any time.
I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law.
If I move to a new address, I will provide that new address to my carrier within 30 days.
I am not listed as a dependent on another person's tax return (unless over the age of 60).
I understand that I may be subject to penalties if I fail to follow these requirements.
I will notify my carrier within 30 days if another member of my household is receiving a Lifeline benefit.
I will notify my carrier within 30 days if I begin receiving more than one Lifeline benefit.
I will notify my carrier within 30 days if I no longer meet the income-based or program-based eligibility criteria.