lifelineform

Date*

National Verifier Application ID*

Name*

First Last

Date of Birth*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone*

Last 4 Digits of your Social Security Number*

Did YOU qualify or a CHILD or DEPENDENT qualify?*

I qualified

My CHILD or DEPENDENT qualified

Child or Dependent's Name*

First Last

Child or Dependent's Date of Birth*

Last 4 Digits of your Child or Dependent's Social Security Number*

How I Qualified*

SNAP

Supplemental Security Income (SSI)

Medicaid (MO HealthNet)

Federal Public Housing Assistance (FPHA)

135% of the Federal Poverty Level

Veterans Pension or Survivors Benefit Programs

How My CHILD or DEPENDENT Qualified*

SNAP

Supplemental Security Income (SSI)

Medicaid (MO HealthNet)

Federal Public Housing Assistance (FPHA)

135% of the Federal Poverty Level

Veterans Pension or Survivors Benefit Programs

I hereby opt-in to the Lifeline Benefit Program.*

I qualify for the program based on income-based or program-based eligibility requirements for the Lifeline Benefit Program.*

I acknowledge that the Lifeline benefit is a government assistance program for eligible consumers. The non-transferable discount is limited to one Lifeline discount per household, and I further certify that no other member of my household is receiving a Lifeline benefit. A household is defined, for the purposes of the Lifeline program, as any individual or group of individuals who live together at the same address and share income and expenses.*

I acknowledge if I move to a new address, I will provide that new address to McDonald County Telephone Company within 30 days.*

I consent to McDonald County Telephone Company disclosing and/or transmitting any information required to the program Administrator for my participation in the program including but not limited to my name, my dependent’s name, date of birth, last 4 digits of social security number, address, telephone number, type of service, start date of service, termination of service date, eligible program, and Independent Economic Household certification date.*

I consent to applying my Lifeline program benefit to the phone or broadband internet service I receive from McDonald County Telephone Company.*

I consent to McDonald County Telephone Company verifying my household’s broadband usage each month to enable McDonald County Telephone Company to claim reimbursement for my program benefit each month if applicable.*

I acknowledge that if McDonald County Telephone Company has a reasonable basis to believe that I am no longer eligible to receive the Lifeline benefit, I will receive a notification of impending termination of my Lifeline benefit and will have 30 days following the date of such notice to demonstrate continued eligibility.*

I acknowledge that I may obtain Lifeline-supported phone or broadband service from any participating provider of my choosing and that I can transfer the Lifeline Benefit to another provider at any time.*

I acknowledge that if I cannot demonstrate eligibility, I will not be enrolled in the program and/or McDonald County Telephone Company is required to de-enroll me from the program.*

I acknowledge that my participation in the Lifeline Program does not relieve my obligations to adhere to McDonald County Telephone Company’s posted rates, terms and conditions, or other rules and regulations or tariffs that govern the services I receive.*

I acknowledge I may be required to re-certify continued eligibility for Lifeline at any time, and the failure to re-certify to continued eligibility will result in de-enrollment and the termination of Lifeline benefits pursuant to § 54.405(e)(4).*

Click here to reference: § 54.405(e)(4). .

Lifeline is a federal benefit and that willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the program.*

I certify that information contained on this form is true and correct to the best of my knowledge. I also certify:*

I have confirmed my eligibility for the Lifeline benefit through the National Verifier.

Signature*

NOTE: THIS RECORD AND ANY RELATED DOCUMENTATION OF ELIGIBILITY MUST BE MAINTAINED FOR AS LONG AS THE SUBSCIBER RECEIVES LIFELINE BUT NO LESS THAN THREE FULL PRECEDING CALENDAR YEARS.

Lifeline Opt-In