NORTH CAROLINA LIFELINE/LINK UP LIFELINE Self Certification Form
User Manual: LIFELINE Self Certification form
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- NORTH CAROLINA LIFELINE/LINK-UP
- SELF-CERTIFICATION LETTER
- Billing Name: ___________________________________________________
- Service Address: ________________________________________________
- City State Zip: __________________________________________________
- Telephone Number: ______________________________________________
NORTH CAROLINA LIFELINE/LINK-UP
SELF-CERTIFICATION LETTER
Billing Name: ___________________________________________________
Service Address: ________________________________________________
City State Zip: __________________________________________________
Telephone Number: ______________________________________________
I hereby certify that I participate in the following public assistance program(s):
__ Medicaid
__ Low Income Home Energy Assistance Program (LIHEAP)
__ Federal Public Housing Or Section 8 Assistance (FPHA)
__ Supplemental Security Income (SSI)
__ Food & Nutrition Services (Food Stamps)
__ Temporary Aid to Needy Families or Work First
Lifeline provides a monthly discount on your local telephone bill. If you do not have a
telephone, Link-Up provides a 50% discount, up to $30, on the cost of connecting local
telephone service. If you receive any one of the public benefits listed above and the
telephone service is in your name, then you can receive Lifeline/Link-Up benefits. Only
one Lifeline benefit is available per household. Long distance call blocking is available
to Lifeline recipients at no charge upon request.
I certify, under penalty of perjury, that I am a current recipient of the above program(s)
and will notify my telecommunications service provider when I am no longer
participating in at least one of the above-designated program(s). I authorize my
telecommunications service provider or its duly appointed representative to access any
records required to verify these statements to confirm my continued participation in the
above program(s). I authorize representatives of the above program(s) to discuss
with/or provide copies to my telecommunications service provider, if requested by the
company to verify my participation in the above program(s) and my eligibility for
Lifeline/Link-Up.
____________________________________ _____________
Applicant’s signature Date
