LIFELINE AND LINK-UP ASSISTANCE APPLICATION

Transcription

1 LIFELINE AND LINK-UP ASSISTANCE APPLICATION Whether you re a first-time applicant or missed your recertification deadline, you must complete and submit a new application form. The easiest way to apply is to print out this application, provide copies of your supporting documents, and mail it to: 600 Telephone Ave. MS 55 Anchorage, AK (855) alaskacommunications.com/lifeline

2 SECTION ONE: PROGRAM SELECTION 1.1 Initial here for home phone service SECTION TWO: IMPORTANT INFORMATION Read and initial each of the following statements: 2.1 Lifeline is a federal benefit and making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the program. 2.2 Only one Lifeline service is available per household. 2.3 A household is defined as any individual or group of individuals who are living together at the same address and one economic unit. This means that the applicant does not share expenses or income with another household at the same address. 2.4 A household is not permitted to receive Lifeline benefits from multiple providers. 2.5 Violation of the one per household limitation constitutes a violation of the program rules and will result in de-enrollment from the program. 2.6 Lifeline is a non-transferable benefit and the subscriber may not transfer his/her benefits to any other person. 2.7 I agree to let Alaska Communications share the required information regarding my eligibility with the Universal Service Administrative Company (USAC). 2.8 Enhanced Lifeline is a benefit offered on Tribal Lands. SECTION THREE: YOUR CONTACT INFORMATION 3.1 Last Name (Required) First Name (Required) Middle 3.2 Last 4 Digits of Social Security or Tribal ID number (Required) Date of Birth (Required) Physical Address: 3.3 Physical Address (No PO Box) (Required) City State Zip Code 3.4 Billing Address if Different from Physical (Required) City State Zip Code Please indicate whether your address is permanent or temporary (Required): Permanent Address (Must notify us within 30 days if subscriber moves) Temporary Address * *If temporary address, contact information must be updated every 90 days.

3 SECTION FOUR: THE PHONE NUMBER YOU NEED LIFELINE SERVICE ON: 4.1 I authorize Alaska Communications to add Lifeline to the following telephone number: (The Representative will complete if this is a new application.) Home Phone Number LIFELINE AND LINK-UP ASSISTANCE APPLICATION SECTION FIVE: YOUR HOUSEHOLD INFORMATION 5.1 Does your spouse or domestic partner (someone you are married to or in a relationship with) already receive a Lifeline-discounted phone? (Check no if you do not have a spouse or partner) YES If you checked YES, stop filling out this form. You may not sign up for Lifeline because someone in your household already receives Lifeline. Only ONE Lifeline discount is allowed per household. NO If you checked NO, go to question Other than a spouse or partner, do any other adults (people over the age of 18 or emancipated minors) live with you at your address? YES If you checked YES, go to question 5.3 NO If you checked NO, skip to section 5.6 and sign and date the worksheet (you do not need to answer questions 5.3, 5.4 or 5.5). 5.3 Other than a spouse or partner, which other adults (people over the age of 18 or emancipated minors) live with you at your address? Parent(s) Roommate(s) Adult son(s) or daughter(s) Another adult relative (such as a sibling, aunt, cousin, grandparent, grandchild, etc.) Other 5.4 Do you share living expenses (bills, food, etc.) and share income (either your income, the other person s income or both incomes together) with at least one of the adults listed above in question 5.3? YES NO If you checked YES, then your address includes only one household. You may not sign up for Lifeline if someone in your household already receives Lifeline. If you checked NO, then your address includes more than one household. Please initial lines 5.5 and 5.6 below, and sign and date the worksheet. Initial: 5.5 I certify that I live at an address occupied by multiple households. 5.6 I understand that violation of the one-per-household requirement is against the Federal Communication Commission s rules and may result in me losing my Lifeline benefits, and potentially, prosecution by the United States government. 5.7 Signature Date

4 SECTION SIX: PROVIDE DOCUMENTATION: 6.1 In order to receive assistance, you must verify you are eligible. Choose one of these two methods: I choose to verify by my participation in an assistance program. If selected go to question 6.2 I choose to verify by my household income. If selected skip question 6.2 and go to question I currently participate in or receive benefits from one of the below programs: If the program beneficiary is someone other than the applicant on this form, provide their name: Name of Eligible Family Member Last Name (Required) First Name (Required) Eligible Family Member does not currently have a separate Lifeline Service: True False Documentation Verifying Family Member Eligibility. Select one of the following programs you receive benefits from and provide documentation: Name Of Program National School Lunch Program (free meals program only) State of Alaska Heating Assistance Program Bureau of Indian Affairs (BIA) General Assistance Head Start Programs (meeting income qualifying standards) Denali Kid Care Tribally Administrated Temporary Assistance for Needy Families (TANF) The Supplemental Nutrition Assistance Program (SNAP) previously known as Food Stamps WIC (Women Infants & Children) Program Adult Public Assistance (including Aid to Aged, Blind & Disabled) Low Income Housing Tax Credit Program Federal Public Housing Assistance / Section 8 Programs Medicaid (not Medicare) VA Disability Pension (VA Disability Compensation does not qualify) Senior Care Child Care Assistance Alaska Temporary Assistance Program (ATAP) Alaska State Housing Corporation Programs: Public Housing Interest Rate Reduction for Low Income Borrowers Home Investment Partnership Program HOME Low Income Home Energy Assistance Programs Senior Citizen Housing Development Fund Supplemental Security Income Verified By:

5 6.3 Income Eligibility If a qualifying program is not selected, you may qualify by income: There are members of my household and my household income is at or below 135% of the Federal Poverty Guidelines. (Note: You must provide documentation verifying your household income, when providing documents pertaining to monthly benefits or wages, you must provide 3 consecutive months of proof.) Poverty Guidelines for Alaska 2016 Federal Poverty Guidelines 135% Household Size Alaska 1 $20,034 2 $27,027 3 $34,020 4 $41,013 5 $48,006 6 $54,972 7 $61,992 8 $69,012 For each additional person, add $7,020 Please Note: Source: Federal Register, Vol. 81, No. 15, January 25, 2016, pp The Federal poverty guidelines are typically updated at the end of January. 6.4 Documentation of household income must be provided in one of the following forms: Documentation Reviewed A previous year s state or federal tax return A current income statement from an employer or 3 months of paycheck stubs A statement of benefits from the U.S. Social Security Administration A statement of benefits from the U.S. Department of Veterans Affairs A retirement of pension statement of benefits An Unemployment or Worker s Compensation statement of benefits A federal or Tribal notice of letter of participation in General Assistance A divorce decree or child support document containing income information Any other official document to substantiate income Verified By:

6 SECTION SEVEN: LONG DISTANCE & ACTIVATION FEES: 7.1 I want to restrict my phone number so long distance calls cannot be placed on this phone. 7.2 I want to make long distance calls and I will allow and pass a credit check or provide a deposit as is policy with Alaska Communications. 7.3 I, or a member of my household, have received assistance with an activation or service order fee (called Link-Up Service) previously at this location. Only one benefit of assistance can be received at this address. I have read the information on this application and understand that I must meet the above qualifications to receive Lifeline and Link-up assistance. I understand that Lifeline support is only available for a single telephone line at my principle residence and if I am currently receiving Lifeline benefits on another Alaska Communications account those benefits will be discontinued. I understand that I may not receive Link-up assistance more than once at the same principle residence. I understand that completion of this application does not constitute immediate enrollment in this program and that service will be provided subject to the terms and conditions of the Alaska Communications local exchange tariffs. I hereby certify under penalty of perjury that the information contained on this application is true and correct and that I have not omitted to check any applicable blocks above. I agree to notify Alaska Communications within five (5) calendar days if (a) my household income exceeds 135% of the federal poverty guidelines or (b) I no longer participate in the program(s) identified above. I agree to notify Alaska Communications if I move to a new address within 30 days of that date. In the event that Alaska Communications determines that I (or, I and any member of my household) have more than one Lifeline account, the original service will remain however subsequent accounts will be terminated immediately. I understand that I will be required to re-certify every year to retain my continued eligibility for Lifeline and that failure to re-certify to my continued eligibility will result in de-enrollment and the termination of my Lifeline benefits. 7.4 Customer Signature Date 7.5 Alaska Communications Rep Signature Date Under FCC rules, providers of Lifeline and Link-up service must securely retain the documentation that was reviewed to verify your eligibility for enrollment in the Lifeline program, to help resolve disputes, audits, or investigations involving these services.