|
Name:
|
_____________________________________SSN:____________________ |
| |
(Last) (First) (Middle)
|
| |
|
|
Address:
|
_____________________________________________________________ |
| |
(Street) (City) (State) (Zip)
|
| |
|
|
Phone number where you may be reached or receive messages:_____________________
|
|
Please answer the following questions (indicate by check
mark):
|
| |
|
1. By filling out this application I (the applicant) request:
|
| |
_________Low-income telephone connection
assistance (Link-Up) and/or |
|
|
_________Low-income monthly telephone
bill assistance (Lifeline) |
| |
|
2. Have you received telephone connection (Link-Up)
assistance at the above address?
|
| |
_________Yes |
| |
_________ No |
| |
If the answer is “yes,” you are not eligible to receive
telephone connection (Link-Up) assistance.
|
| |
|
|
3. Are you currently participating in any of the following
programs:
|
| |
_________Medicaid (e.g. Title XIX/Medical,
State Supplemental Assistance) |
| |
_________Food Stamps |
| |
_________Supplemental Security Income
(SSI) |
| |
_________Federal Public Housing Assistance |
| |
_________Low_Income Home Energy Assistance
Program (LIHEAP) |
|
_________Temporary Assistance to Needy
Families Program (TANF) |
|
_________National School Lunch Program
(NSL) |
| |
|
| 4. Is your income at
or below 135 percent of the Federal Poverty Guidelines? ___Yes
___ No |
|
|
|
I understand completion of this application does not constitute
immediate acceptance into this program. I agree to notify
my telecommunications provider if I cease to participate
in any of the public assistance programs I checked above
or if my income becomes greater than 135 percent of the Federal
Poverty Guidelines.
|
| |
|
I certify under penalty of perjury the above information
is true. I have read the information on this application
and understand that I must meet the above qualifications
to receive assistance from these programs.
|
| |
|
Signature:
|
_____________________________________Date: ______/______/______
|
| |
|
|
|
|
|
