Application Lifeline Form Printable Details

The table offers specifics of the application for verizon lifeline service. There, you will get the specifics of the document you want to fill out, such as the approximate time required to complete it and also other data.

QuestionAnswer
Form NameApplication For Verizon Lifeline Service
Form Length4 pages
Fillable?Yes
Fillable fields57
Avg. time to fill out12 min 28 sec
Other namesmassachusetts application verizon lifeline, application lifeline form, application lifeline form printable, application lifeline service form

Form Preview Example

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)

________________________________________

 

Billing Name On Home Telephone Account _______________________________________________________

 

 

 

(last)

(first)

(middle initial)

 

Home Address: _______________________________________ __________

__________________________________________

(number)

(street)

(apartment number, if applicable)

(city or town)

(state) (zip code)

Alternative Contact Number (other than Home Telephone Number)

______________________________

 

Please indicate below if the home address listed above is your permanent or temporary address?

Permanent

Temporary

 

 

 

Billing Address if different from Home Address

 

 

 

 

_______________________________________________________________________________________________

 

(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

 

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:

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

 

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

___ ___

____ ____

____ ____ ____ ____

 

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

 

Poverty Levels

 

 

1

$15,755

 

 

2

$21,236

3

$26,717

 

 

4

$32,198

 

 

Each additional person after 4

$5,481

 

 

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.

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 _____________________

 

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

Page 4 of 4

How to Edit Application For Verizon Lifeline Service

Completing the verizon lifeline form file is a breeze with this PDF editor. Stick to these particular actions to create the document right away.

Step 1: Look for the button "Get Form Here" on the website and select it.

Step 2: It's now possible to manage your verizon lifeline form. The multifunctional toolbar helps you add, remove, transform, and highlight text or carry out similar commands.

These particular segments will create the PDF template that you will be creating:

portion of fields in massachusetts application verizon lifeline

Type in the demanded details in the field Alternative Contact Number (other, PLEASE READ CAREFULLY, PROGRAM PARTICIPATION AND, PLEASE READ CAREFULLY,  Bureau of Indian Affairs (BIA),  SNAP (Supplemental Nutrition, and known as Food Stamps).

massachusetts application verizon lifeline Alternative Contact Number (other, PLEASE READ CAREFULLY, PROGRAM PARTICIPATION AND, PLEASE READ CAREFULLY,  Bureau of Indian Affairs (BIA),  SNAP (Supplemental Nutrition, and known as Food Stamps) blanks to fill out

You're going to be expected to provide the data to help the application fill in the segment Please provide the following, Last 4 digits of the Social, Date of birth ___ ___ ____ ____, 2 Digit Month 2 Digit Day 4 Digit, The last 4 digits of the Social, and INCOME ELIGIBILITY GUIDELINES.

stage 3 to completing massachusetts application verizon lifeline

Please be sure to record the rights and responsibilities of the sides within the 1 2 3 4 Each additional person, 135% of Federal Poverty Levels, number of individuals in your, _______ Individuals live in my, If your household qualifies based, current income statement from an,  (cid:455)ou(cid:396), and federal or Tribal notice letter of box.

Entering details in massachusetts application verizon lifeline step 4

Finish by reading the following areas and filling in the relevant information: Billing Name Signature,  I certify the individual (if,  I certify the individual (if, and PLEASE FAX OR MAIL SIGNED.

Filling in massachusetts application verizon lifeline part 5

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