Application for Verizon Lifeline Service (Massachusetts)
(Discounted Telephone Service)
PLEASE READ CAREFULLY, USE PEN, PRINT AND FILL OUT COMPLETELY
Billing Telephone Number (including area code) |
________________________________________ |
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Billing Name On Home Telephone Account _______________________________________________________ |
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(last) |
(first) |
(middle initial) |
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Home Address: _______________________________________ __________ |
__________________________________________ |
(number) |
(street) |
(apartment number, if applicable) |
(city or town) |
(state) (zip code) |
Alternative Contact Number (other than Home Telephone Number) |
______________________________ |
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Please indicate below if the home address listed above is your permanent or temporary address?
Permanent |
Temporary |
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Billing Address if different from Home Address |
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_______________________________________________________________________________________________ |
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(number) |
(street) |
(apartment number, if applicable) |
(city or town) |
(state) (zip code) |
PROGRAM PARTICIPATION AND CERTIFICATION
I certify under penalty of perjury that I or a member of my household meet the income-based or program-based eligibility criteria for receiving the Lifeline discount. I or a member of my household receive benefits from the following program (check only one program):
Medicaid |
SNAP (Supplemental Nutrition Assistance Program, formerly |
Supplemental Security Income (SSI) |
known as Food Stamps) |
Low Income Home Energy Assistance Program |
Bureau of Indian Affairs (BIA) General Assistance |
Emergency Aid to the Elderly, Disabled and Children |
Head Start (Tribal land residents only) |
Transitional Aid to Families & Dependent Children |
Food Distribution Program (Tribal land residents only) |
Section 8 Federal Public Housing Assistance |
National School Free Lunch Program |
Eligibility based on income (see page 3) |
Temporary Assistance for Needy Families |
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MassHealth |
Along with this application, please attach or fax a photocopy (do not send an original) of one of the following that matches the program checked above:
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ou u e t o p io ea ’s state e t of e efits f o a ualif i g state, fede al o T i al p og a |
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or |
a notice letter of participation in a qualifying state, federal or Tribal program or
a program participation document, for example, benefit card or
an official document indicating your participation in a qualifying state, federal or Tribal program.
Page 1 of 4
PLEASE READ AND CERTIFY THE FOLLOWING PROGRAM RULES
The Lifeline discount program is a federal benefit and willfully making false statements to obtain this benefit can result in fines, imprisonment, de-enrollment or being barred from the program. Verizon is required by the Federal Communications Commission, or FCC, to verify your eligibility to participate in the Lifeline discount program.
Under penalty of perjury you must certify the following statements are true to the best of your knowledge. Please indicate your acknowledgement of each statement by a checkmark.
Only one Lifeline discount is allowed per household, consisting of either wireline or wireless service. A household is not permitted to receive Lifeline benefits from multiple providers. Violation of the one-per-household requirement constitutes a violation of Federal Communications Commission rules and will result in your de-enrollment from the program, and potentially, prosecution by the United States government.
A household is defined as any individual or group of individuals who live together at the same address and share income and expenses.
I certify my household will receive only one Lifeline service and, to the best of my knowledge, my household is not already receiving a Lifeline service.
Your name, telephone number, address and information contained in this application, as well as information associated with your Lifeline service may be provided to the Universal Service Administrative Company (USAC - administrator of the Lifeline discount program) and/or its agents for the purpose of verifying your household does not receive more than one Lifeline benefit. You will be denied Lifeline benefits if you fail to provide Verizon with consent to provide the specified information to USAC.
I acknowledge and consent that Verizon may provide my name, telephone number, address and information contained in this application, as well as information associated with your Lifeline service to the Universal Service Administrative Company (USAC) and/or its agents for the purpose of verifying that I or another member of my household does not receive more than one Lifeline benefit.
I agree to allow Verizon to exchange any necessary information with the appropriate federal or state agency, or fund administrator, to verify my eligibility to participate in the Lifeline discount program.
Lifeline service is a non-transferable benefit. You may not transfer your Lifeline service to any individual, including another eligible low-income consumer.
I agree not to transfer my Lifeline discount benefit to another person.
I agree to notify Verizon within 30 calendar days if I move to another address and to provide the new address.
I agree to notify Verizon within 30 calendar days if, for any reason, I or my household:
-No longer receive benefits from the federal or state program that qualified me for the Lifeline discount program.
-Annual household income exceeds the Federal Poverty amount listed on page 3 that qualified me for the Lifeline discount program.
-Receives more than one Lifeline benefit or another member of my household is receiving a Lifeline service.
I acknowledge that I may be required to recertify my continued eligibility for Lifeline at any time and my failure to recertify will result in de-enrollment and termination of my Lifeline benefits.
I agree to participate in the certification of my continued eligibility in the Lifeline discount program.
The information contained in this application form is true and correct to the best of my knowledge.
I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law.
Page 2 of 4
REQUIRED INFORMATION
Please provide the following information of the household member receiving benefits:
Last 4 digits of the Social Security Number* |
___ ___ ___ ___ |
Date of birth |
___ ___ |
____ ____ |
____ ____ ____ ____ |
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2 Digit Month |
2 Digit Day |
4 Digit Year |
The last 4 digits of the Social Security Number and Date of Birth must be for a person 18 years or older.
* If you do not have a Social Security Number and live on Federally-recognized Tribal lands, please complete the following:
I certify that I live on Federally-recognized Tribal lands. My Tribal identification number is: ________________________
INCOME ELIGIBILITY GUIDELINES
The following chart can be used to determine eligibility for the Lifeline discount program based solely on income level. You may qualify for the Lifeline discount program if your household annual income is at or below 135% of the Federal Poverty Guidelines. A household is defined as any individual or group of individuals who live together at the same address and share income and expenses.
The chart below lists the annual income amount that cannot be exceeded in order to qualify based on household size. If the annual income amount for your household size is more than the amount shown on the chart below you do not qualify for the Lifeline discount based solely on income.
Household Size |
135% of Federal |
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Poverty Levels |
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1 |
$15,755 |
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2 |
$21,236 |
3 |
$26,717 |
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4 |
$32,198 |
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Each additional person after 4 |
$5,481 |
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Please indicate on the line below the
number of individuals in your household.
_______ Individuals live in my household
If your household qualifies based on the above income chart, please attach or fax a photocopy (do not send an original) of the following applicable documents. If you provide documentation that does not cover a full year (such as current pay stubs), you must submit three (3) consecutive months worth of the same type of document from the previous 12 months.
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ou p io ea ’s state, fede al o T i al ta etu . |
current income statement from an employer or paycheck stub.
a Social Security statement of benefits.
a Veterans Administration statement of benefits.
a retirement or pension statement of benefits.
a U e plo e t o Wo k e ’s Co pe satio state e t of e efits
federal or Tribal notice letter of participation in General Assistance
a divorce decree
a child support award
other official document containing income information
Page 3 of 4
PLEASE SIGN AND DATE THIS APPLICATION FORM AND PROVIDE PROGRAM BENEFICIARY NAME
Billing Name Signature _____________________________________________________________ |
Date _____________________ |
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Name of Household Member Receiving Benefits _____________________________________________________________ |
or Self |
Relationship of Household Member Receiving Benefits to the Account Billing Name |
________________________ |
or Self |
I certify the individual (if different from the Billing Name) named on the documentation demonstrating program participation is part of my household.
I certify the individual (if different from the Billing Name) named on the documentation demonstrating program participation is not already receiving a Lifeline service.
PLEASE FAX OR MAIL SIGNED APPLICATION AND PROOF OF ELIGIBILITY TO:
Fax Number: 877-306-6175
Or mail to:
Verizon Lifeline Services
PO Box 33075
St. Petersburg, FL 33733-8075
If you have any questions, please call 1 800 VERIZON
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