Lifeline_application Lifeline Application
User Manual: lifeline_application
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Effective: December 2, 2016 November 29, 2016 Star Communications Lifeline Application/Certification Form Application for Lifeline: Lifeline is a federal benefit and willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the program. Only one Lifeline service is available 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 is not permitted to receive Lifeline benefits from multiple providers. Violation of the one-per-household limitation constitutes a violation of the Federal Communications Commission’s (or “FCC”) rules and will result in the subscriber’s de-enrollment from the program. Lifeline is a non-transferable benefit and the subscriber may not transfer his or her benefit to any other person. How to apply: 1. Choose whether you will apply because you participate in a qualifying program or because your total household income falls within the guidelines. 2. Fill out the form on the back. You must indicate your service address, billing address (if not the same as your service address), SSN and date of birth. 3. You must provide photocopies of either the program or income documents. 4. You must sign the bottom of the application indicating that you are complying with the Lifeline benefit rules. How to recertify: 1. Check appropriate box on the back of this form. 2. Return this form with your signature to the cooperative within 30 days of receipt. Qualifying Methods You may qualify for Lifeline either because you participate in one of the following programs or because your income is within the following guidelines. NOTE: You may receive Social Security and Medicare benefits, but to qualify for Lifeline, you must receive benefits from one of the following programs or your income must fall within the guidelines. NEW APPLICANTS - You MUST send photocopies of any qualifying documentation. NOTE: SEND PHOTOCOPIES ONLY; WE WILL NOT RETURN ANY DOCUMENTATION. Program Eligibility Supplemental Nutrition Assistance Program Survivors Benefits (SNAP) Supplemental Security Income Federal Public Housing/Section 8 (SSI) Medicaid Federal Veterans Pension Documentation includes a photocopy of a benefit card, statement of benefits, or an award letter issued in the current or previous year. Income Eligibility Annual Income 135% Thresholds Based on Household Size 1 2 3 4 5 6 7 8 $16,038 $21,627 $27,216 $32,805 $38,394 $43,983 $49,586 $55,202 For each additional person + $5,616/person Documentation needed to qualify for Lifeline through income is noted on next page. 1 Effective: December 2, 2016 November 29, 2016 Star Communications Lifeline Application/Certification Form When completed, mail or fax form to: Star Communications, P.O. Box 348, Clinton, NC 28329 Fax to 910-564-2549 Customer Name: _____________________________________________________________________ Customer Service Address: _______________________________Temporary(required): Yes: __No: __ City: _______________________State: ________________Zip Code: __________________________ Customer Bill Address: ________________________________________________________________ City: _______________________State: ______________Zip Code: ____________________________ Customer’s Home Telephone: ___________________________________________________________ Customer’s Social Security Number: _____________________________________________________ Customer’s Date of Birth xx/xx/xxx: _____________________________________________________ New Applicant Recertification – documentation is not necessary Sign and return within 30 days of receipt or discount will be denied. Please choose 1 OR 2: 1. I certify that I participate in at least one of the following programs (check all that apply) and (NEW APPLICANT ONLY) I am providing a photocopy of a document that demonstrates my participation in one of these programs. NOTE: SEND PHOTOCOPIES ONLY; WE WILL NOT RETURN ANY DOCUMENTATION. Supplemental Nutrition Assistance Program (SNAP) Survivors Benefit Federal Veterans Pension Federal Public Housing/Section 8 Medicaid Supplemental Security Income (SSI) If discount is based on someone other than the qualifying member, list relationship to qualifying member and complete the following: Name: __________________ DOB: __________ SSN: _________________ Relationship to Qualifying Member: _________________ 2. I certify that my total household income falls within the guidelines listed on Page 1 and I also certify that this is how many people live in my household (required): Adults ____ Children _____. (NEW APPLICANT ONLY) I am providing a photocopy of the following qualifying documents: Prior year’s state or federal tax return Divorce Decree Current income statement from an employer Retirement/Pension Statement of Benefits Child Support Document Unemployment/Workmen’s Compensation Statement of Benefits Paycheck stubs for 3 consecutive months (within Federal notice letter of participation in General Assistance the last 12 months) Veterans Administration Statement of Benefits Social Security Statement of Benefits Other official document containing income information I certify, under penalty of perjury, that: 1. _____I meet the income-based or program-based eligibility criteria for receiving Lifeline, shown above. 2. _____I will notify the carrier within 30 days if for any reason I no longer satisfy the criteria for receiving Lifeline including, as relevant, if I no longer meet the income-based or program-based criteria for receiving Lifeline support, I am receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline benefit. 3. _____If I move to a new address, I will provide that new address to Star Communications within 30 days. 4. _____My household will receive only one Lifeline service and, to the best of my knowledge, my household is not already receiving a Lifeline service. 5. _____The information contained in this certification form is true and correct to the best of my knowledge. 6. _____I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law. 7. _____I acknowledge that I may be required to re-certify my continued eligibility for Lifeline at any time, and my failure to re-certify my continued eligibility will result in de-enrollment and the termination of my Lifeline benefits. I hereby authorize Star Communications to release any of my information contained in this Lifeline Application required for the administration of the Lifeline program to the FCC or its designee, including the Universal Service Administrative Company, and to any state and federal agency, as required by law. Date of Eligibility of Benefits received: _______________________________________ Applicant’s Signature: _____________________________________Date: ___________________________ For agent use only: Cooperative Reviewing Representative Name: _________________________________________ Date Reviewed: _______________ Type of document for program eligibility: __________________ Type of document for income eligibility: ________________________ 2
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