2021 Minnesota TAP Application LQ
Telephone discount, Telephone application, Lifeline application, TAP application, Government phone application, Obamaphone application
Minnesota Public Utilities Commission
PDF
2021 Minnesota TAP Application LQ Telephone Assistant Plan (TAP) Application
All personal information is kept confidential. If your application is illegible or incomplete, your discounts will be delayed. Step 1: Fill out information about the applicant.
Name: __________________________________________________________________________________________ Last Four Digits of Social Security Number OR Tribal ID Number: _______ Birthdate (MM/DD/YYYY): ___/___/_______ Mailing Address: __________________________________ City: _________________ State: MN Zip code: _________ This is a temporary address. YES NO More than one family lives here. YES NO Billing Address (if different): _________________________ City: _________________ State: ___ Zip code: _________ Telephone number where you can be reached: (_______) _______ - __________ Telephone company where you want discount: _________________________________________________________ Telephone account number if you have service now: _____________________________________________________
Step 2: Fill out either Eligibility Option 1 OR Eligibility Option 2 Option 1: Program Eligibility
Check the program you or a member of your household participate in and attach documentation. Federal Public Housing Assistance (FPHA) Medicaid/Medical Assistance (MA) Supplemental Nutrition Assistance Program (SNAP) Supplemental Security Income (SSI) Veterans Pension and Survivors Benefit programs
Check the Tribal program you or a member of your household participate in and attach documentation. Bureau of Indian Affairs General Assistance Food Distribution Program on Indian Reservations (FDPIR) Tribally Administered Head Start (for those meeting income-qualifying standards) Tribally Administered Temporary Assistance for Needy Families (TTANF)
I live on tribal lands. YES NO Name of program participant: _______________________________________________________________________ The program participant is a member of my household. YES NO
Option 2: Income Eligibility I do not participate in any of the programs listed in Eligibility Option 1. Instead, my gross yearly income is at or below 135% of the Federal Poverty Guidelines. Check whichever option best matches your household.
1-person household with income at or below $17,388 2-person household with income at or below $23,517 3-person household with income at or below $29,646 4-person household with income at or below $35,775 5-person household with income at or below $41,904 6-person household with income at or below $48,033 For each additional person, add $6,129 Attach one of the documents below. Child support award/Divorce decree Current pay stubs or other official documentation of income for the last three months Last year's State, Federal, or Tribal tax return Retirement/Pension benefits statement Unemployment/Workers compensation statement Veterans Administration benefits statement How many people are living in my household? _______ I certify the number of people living in the household to be true. I certify I have presented all income for all members of my household and myself.
January 2021
Initial each certification.
Step 3: You must initial each certification and sign this application. I understand TAP is a state discount and is non-transferable. Initial here: [Initial here]
I meet the income-based or program-based eligibility criteria for receiving TAP. Initial here: [Initial here]
I will notify the service provider within 30 days if I no longer qualify for TAP, including: if I no longer meet the income-based or program-based support; if I am receiving more than one TAP benefit; and if another member of my household is receiving a benefit. A household is defined as any group of individuals who live together at the same Initial here: [Initial here]
I will provide the new address to my service provider within 30 days if I move. Initial here: [Initial here] My household can only receive one TAP benefit, and my household is not already receiving a TAP benefit. A household is defined as any group of individuals who live together at the same address and share income Initial here: [Initial here]
The information contained in my certification form is true and correct to the best of knowledge. Initial here: [Initial here] I acknowledge that providing any false or fraudulent information to receive TAP benefits is punishable by law. Initial here: [Initial here] I may be required to recertify my continued eligibility for TAP at any time, and my failure to certify as to my continued eligibility will result in de-enrollment and the termination of my TAP benefits. Initial here: [Initial here]
I certify that I am seeking to qualify for TAP as an eligible resident of tribal lands and live on tribal lands.
If seeking to qualify as an eligible resident of tribal lands, initial here: [Initial here] Step 4: You must sign this declaration under penalty of perjury.
By signing below, I declare under penalty of perjury that I understand and agree to all of the following:
· The information contained in this form is true and correct to the best of my knowledge. · I will inform the company within 30 days if I no longer satisfy the criteria for receiving the discount. · If I move to a new address, I will provide the company with that address within 30 days. I do not receive more than one discount. Applicant Signature (Required): __________________________________________________ Date: ______________
(Optional) If you designate an Authorized Representative for this application, this person must fill in this section to say they completed this form on your behalf and is willing to assist you in seeking telephone service discounts. Print Authorized Representative Name: _______________________________________________________________ Authorized Representative Signature: _________________________________________________________________
Authorized Representative's Phone Number: (_______) _______ - __________ Date: ___________________________
Questions? Please contact your telephone or broadband company.
Complete application. Attach program participation or proof of income. Contact a company where you want the discount before submitting application for the proper mailing address. Mail application and income documents to:
CenturyLink, P.O. Box 2738, Omaha, NE 68103-2738 Fax: 402-998-7341 Customer Service: 800-244-1111 Email: TAPCenter@centurylink.com The Minnesota Public Utilities Commission (MPUC) regulates the TAP program. If you have an issue with your telephone or broadband company, contact the MPUC at 651.296.0406 or 1.800.657.3782.
January 2021
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