Apply for a Free Mobile Phone & Free Service

Transcription

1 Apply for a Free Mobile Phone & Free Service Through the government-supported Lifeline program, you may qualify for free service. See inside for details. This is a State of Hawaii Enrollment Form. For other state forms or questions, please call or go to 1

2 HAWAII WHAT IS THE LIFELINE PROGRAM? Lifeline is a federal government-supported program that provides free mobile phone services to qualified low-income customers. If you qualify, you will receive a free mobile phone, a limited amount of free wireless service, and unlimited access to 911 and customer service. For more information or assistance, call HOW DO I QUALIFY FOR THE LIFELINE PROGRAM? You qualify for Total Call Mobile Lifeline Plans in the State of Hawaii if you, a dependent, or a household member, are enrolled in certain government programs or if your household income is at or below certain income limits. See below for qualifying programs and income levels. WHAT PLANS CAN I SIGN UP FOR IF I QUALIFY FOR THE LIFELINE PROGRAM? If you qualify for the Lifeline program, you may choose from any of the Lifeline Plans below. Lifeline Plan 1 is available at no cost to you unless you purchase additional minutes or text messages. Alternatively, you may also choose certain Total Call Mobile prepaid plans at discounted rates under Lifeline Plans 2, 3, 4 & 5. All of Total Call Mobile s Lifeline Plans include: A free basic phone (selected by Total Call Mobile; call customer service for upgrade options) Free customer service calls. Free 911 and balance inquiry calls. Free voic , Caller ID, and Call Waiting. For additional minutes, text messages, or international calls, load a regular Anytime Plan refill or call customer service at Check the monthly plan that you would like to sign up for: Minutes Minutes Text Messages Text Messages Data Data o Plan 1 (250 minutes per month for free) 250 $0.10 / min. 1 text = 1 Plan Minute $0.05 / text 0 Unavailable o Plan 2 (Discounted 1000 Talk & 1000 Text for $19.99 per month) 1000 $0.10 / min $0.05 / text 0 Unavailable o Plan 3 (Discounted Talk for $19.99 per month) NA 0 $0.05 / text 0 Unavailable o Plan 4 (Discounted Talk & Text for $29.99 per month) NA NA 0 Unavailable o Plan 5 (Discounted Talk, Text & Data for $39.99 per month) (first 1GB at up to 3G speeds; speeds reduced to up to 128 Kbps for remainder of plan cycle) NA NA (first 1GB at up to 3G speeds; speeds reduced to up to 128 Kbps for remainder of plan cycle) NA SERVICE TERMS & CONDITIONS Comprehensive terms and conditions are available at Total Call Mobile ( TCM ) service is for personal use within the United States, Puerto Rico, and the U.S. Virgin Islands. does not mean unreasonable use. Unreasonable use includes, but is not limited to, conference calling, monitoring services, abnormally large data transmissions, broadcast, telemarketing, autodialed calls, commercial uses, an abnormally high number of calls/messages or abnormally long calls, tethering to another device for data transmission, or any other usage that interferes with TCM s underlying service/network resources. Data is only available for select handsets. Data speed is up to 3G for the first 1GB; speeds reduced to up to 128 Kbps for remainder of plan cycle. International calls are charged at the applicable rate plus airtime. TCM reserves the right to limit picture message size. Governmental taxes and fees will be charged where applicable. Plans, rates and fees are subject to change without notice. The rates herein are valid as of March 31, Unless otherwise indicated on the package, the handset is refurbished/reconditioned. TCM reserves all rights with regard to TCM intellectual property. 2

3 HAWAII To apply for Lifeline service through Total Call Mobile, please complete this form and submit it to the address on the last page. For more information or assistance, call When you submit this application, you must include the supporting documentation indicated below. Supporting documentation will not be returned. 1. CUSTOMER INFORMATION First Name: Last Name: Home Address: City: State: Zip Code: (P.O. Box NOT sufficient) Home Address: o permanent o temporary Date of Birth (MM/DD/YYYY): Last 4 digits of SSN: Phone Number: Public Aid Case Number (if applicable): 2. PROGRAM-BASED ELIGIBILITY To qualify for Lifeline, you must complete either this Section or Section #3 below. Check all program(s) that the person in Section #1 is enrolled in. If you qualify for Lifeline under this Section (i.e. by being enrolled in at least one of the following programs), you must provide current proof of program participation with this application. If any of your dependents or household members participate in the programs below, you can check the box for that program. o Federal Public Housing Assistance (FPHA) / Section 8 o Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps) o Low Income Home Energy Assistance Program (LIHEAP) o National School Lunch Program (free program only) o Supplemental Security Income (SSI) o Temporary Assistance for Needy Families Program (TANF) o Medicaid (not Medicare) 3. INCOME-BASED ELIGIBILITY To qualify for Lifeline, you must complete either this Section or Section #2 above. To qualify based upon your household income, the income of all your household members must be at or below the amount indicated in the table below. If your household size is greater than 8, the maximum annual household income to qualify for Lifeline is the income indicated for 8 household members plus $6,453 for each additional household member. Household Members: (check the box which applies) o 1 o 2 o 3 o 4 o 5 o 6 o 7 o 8 Specify Maximum Annual Household Income: $18,455 $24,881 $31,307 $37,733 $44,159 $50,585 $57,011 $63,464 $ Customer Annual Household Income: $ If you qualify for Lifeline under this Section, attach the most recent State, Federal, or Tribal Tax Return or the most recent statements of income for 3 consecutive months within the prior year from the following sources for each household member: Divorce Decree / Child Support Documents Federal / Tribal General Assistance Participation Letter Paystubs (most recent three consecutive months) Retirement / Pension Benefit Statements Social Security Benefits Statements Unemployment / Workers Compensation Benefits Statements Veterans Administration Benefits Statements W2 Statements 3

4 4. LIFELINE HOUSEHOLD DISCLOSURES Does your household share the same address as other separate households? YES (please continue answering the below questions.) NO (please skip this Section and move on to Section 5 below.) q I hereby certify that I reside at an address occupied by multiple households, including adults who do not contribute income to my household and/ or share in my household s expenses, and I will complete a separate additional form. 1. Does your spouse or domestic partner (that is, 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) If you checked YES, you may not sign up for Lifeline because someone in your household already receives Lifeline. Only ONE Lifeline discount is allowed per household.if you checked NO, please answer question #2. 2. Other than a spouse or partner, do other adults (people over the age of 18 or emancipated minors) live with you at your address? A. A parent B. An adult son or daughter C. Another adult relative (such as sibling, aunt, cousin, grandparent, grandchild, etc.) D. An adult roomate E. Other If you checked NO for each statement above, you do not need to answer the remaining questions. Please initial line B, below, and sign the worksheet. If you checked YES, please answer question #3. 3. 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 #2 If you checked NO, then your address includes more than one household. Please initial lines A and B below, and sign and date the worksheet. If you checked YES, then your address includes only one household. You may not sign up for Lifeline because someone in your household already receives Lifeline. A. I certify that I live at an address occupied by multiple households. B. I Understand that Violation of the one-per-household requirement is against the Federal Communications Commission s rule and may result in me losing my Lifeline benefits, and potentially, prosecution by the United States government. SIGNATURE: (Required) Date: 5. DISCLOSURES A complete and signed Lifeline Service Application and Certification ( Certification ) is required to enroll you in Total Call Mobile s Lifeline service program in your state. This Certification is only for the purpose of verifying your eligibility for Lifeline service and will not be used for any other purpose. Service requests will not be processed until this Form has been received and verified by Company. I understand I have the right to enroll in the Lifeline service using non-electronic methods. I further understand that I have the right to withdraw this consent at any time prior to activation of my service. The Company has advised me that I may request a paper copy of my contract and associated fees by calling 611 from my wireless handset. Lifeline is a government assistance program and willfully making false statements to obtain a Lifeline 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 may not receive multiple Lifeline discounts. You may apply your Lifeline discount to either one landline or one wireless number, but you cannot have the discount on both and you are not permitted to receive Lifeline benefits from multiple providers. Lifeline is a non-transferable benefit and you may not transfer your benefit to any other person, including another eligible low-income consumer. Violation of the one-per-household limitation constitutes a violation of the Federal Communications Commission s rules and will result in your de-enrollment from the program, and potentially prosecution by the United States Government. I hereby certify, under penalty of perjury, that I have read and understood the disclosures listed above and that, to the best of my knowledge, my household is not already receiving a Lifeline service benefit. Activation and usage requirement disclosures: This service is a prepaid service and you must personally activate it by dialing 611 from your handset. To keep your account active, you must use your Lifeline service at least once during any 60 day period by completing an outbound call, purchasing additional minutes from Company, answering an in-bound call from someone other than the Company, or by responding to a direct contact from the Company confirming that you want to continue receiving Lifeline service from Company. If your service goes unused for 60 days, you will no longer be eligible for Lifeline benefits and your service will be suspended (allowing only 911 calls and calls to the Company s customer 4

5 care center) subject to a 30 day cure period during which you may use the service (as described above) or contact the Company to confirm that you want to continue receiving Lifeline service from Company. I hereby certify that I have read and understood the disclosures listed above regarding activation and usage requirements. Authorizations: I hereby authorize the Company to access any records required to verify my statements on this form and to confirm my eligibility for the Lifeline program. I also authorize the Company to release any records required for the administration of the Lifeline program (name, telephone number, address, date of birth, last 4 digits of SSN, amount of support being sought, means of qualification for support, and dates of service initiation and termination), including to the Universal Service Administrative Company, to be used in a Lifeline database and to ensure the proper administration of the Lifeline Program. Failure to consent will result in denial of service. I understand I have the right to enroll in the Lifeline service using non-electronic methods. I further understand that I have the right to withdraw this consent at any time prior to activation of my service. The Company has advised me that I may request a paper copy of my contract and associated fees by calling 611 from my wireless handset. I hereby authorize the Company to send text messages to my Company provided wireless number about my Lifeline benefit. Text messages sent by the Company will not decrement my available wireless minutes or texts. Standard voice, data and text rates will apply to all messages to and from anyone other than the Company. certifications: I hereby certify, under penalty of perjury, that (initial each certification): I meet the income-based or program-based eligibility criteria for receiving Lifeline service and have provided documentation of eligibility. I will notify the Company 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 eligibility criteria, I begin receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline benefit. I understand that I may be subject to penalties if I fail to follow this requirement. I am not listed as a dependent on another person s tax return (unless over the age of 60). The Residential Address listed above is my primary residence, not a second home or business. If I move to a new address, I will provide that new address to the Company within 30 days. If I provided a temporary residential address to the Company, I will verify my temporary residential address as required by law. I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law. My household will receive only one Lifeline service and, to the best of my knowledge, my household is not already receiving a Lifeline service. I acknowledge that I may be required to re-certify my continued eligibility for Lifeline at any time, and my failure to re-certify as to my continued eligibility within 30 days will result in de-enrollment and the termination of my Lifeline benefits. The information contained in this certification form is true and correct to the best of my knowledge. If Total Call Mobile finds that I am already receiving a Lifeline discount benefit from another provider, I agree that I want to transfer my Lifeline discount benefit from that Lifeline provider to Total Call Mobile. I understand that once the transfer is complete, I will lose my Lifeline Program benefit with any other Lifeline provider from which I am currently receiving a Lifeline discount. Total Call Mobile has explained to me and I understand that I may not have multiple Lifeline Program benefits with the same or different providers. By my signature, I hereby certify, under penalty of perjury, that the information contained in this certification form is true and correct to the best of my knowledge. SIGNATURE: (Required) Date: Please mail this application, with supporting documentation to: Total Call Mobile, Lifeline Program 1411 W. 190th Street, Suite 650, Gardena, CA