Otap Application Form – Fill Out and Use This PDF

Please PRINT clearly and SIGN on page 2.

If you have a situation that prevents you from providing certain information, please contact us for assistance.

Applicant’s Legal Name (Last, First, M.I.) (Applicant’s legal name MUST be on phone bill)						Applicant’s Social Security No.		Applicant’s Birth Date
						—	—	/	/
Applicant’s Home Address	Is this a temporary address?				Apt. #	City	State	ZIP
			q Yes q No				OR
Applicant’s Mailing Address (if different from your home address)					Apt. #	City	State	ZIP
							OR
Applicant’s Phone Company (As listed on page 3)		Applicant’s Phone Number				Applicant’s E-mail Address
		(	)	_

I participate in the following qualifying programs (Check any that apply):

_____ SNAP (Supplemental Nutrition Assistance Program; Food Stamps)

_____ SSI (Supplemental Security Income)

_____ TANF (Temporary Assistance for Needy Families)

_____ Certain State Medical Programs or Certain Medicaid Programs

at or below 135% of the federal poverty guidelines

Supporting documentation is required for the following program:

_____ NSLP* (National School Lunch Program; Free Lunch Program Only)

*Please provide a copy of the official letter from your school district indicating your current participation.

Please continue to page 2

1	PUC Form FM784 (5/12) ENG

Please completely READ and SIGN this form that indicates you understand and agree to comply with the following Oregon Telephone Assistance Program (OTAP)/Lifeline rules:

■I understand that completing this application does not immediately approve me for the OTAP/Lifeline benefit. I will be notified in writing of my application status.

■I understand it may take 30-90 days for the phone company to apply the OTAP/Lifeline benefit to my phone bill.

■I give the Oregon Public Utility Commission (PUC) authority to obtain or review any required records needed to confirm my statements and to confirm that I qualify for the OTAP/Lifeline. I also authorize the phone company to release any required records for my OTAP/Lifeline benefit.

■I am head of household and no one else in my household receives landline or wireless OTAP/Lifeline service.

■I understand that the OTAP/Lifeline credit is only allowed for ONE PHONE LINE PER HOUSEHOLD

A household is defined as any persons who live together at the same address and share income and expenses.

■I understand that if I break or violate the one-per-household rule I will no longer qualify for the OTAP/Lifeline program.

■I agree to let the PUC know within 30 days if:

I no longer qualify for the OTAP/Lifeline benefit

I no longer take part in a qualifying program

I receive more than one OTAP/Lifeline benefit

Another member of my household is also receiving the OTAP/Lifeline benefit

■I understand that I have 30 days to notify the PUC if I no longer qualify for the OTAP/Lifeline benefit or I may be removed from the program.

■I agree to notify the PUC of address changes within 30 days of moving.

■I understand that my OTAP/Lifeline benefit may not be transferred or given to any other person.

■I understand that I may be required to confirm that I still qualify for the OTAP/Lifeline benefit at any time and that, if I do not comply, my OTAP/Lifeline benefits will stop.

■I understand that OTAP/Lifeline is a state and federal benefit and willfully making false statements

or providing false or fraudulent documents to obtain the benefit is punishable by law and can result in fines, imprisonment, disqualification or being permanently removed from the program.

By signing this application I certify under penalty of perjury that the information contained in this application is true and correct and that I meet the eligibility criteria for the OTAP/Lifeline benefit.

Applicant Signature ______________________________________________________________

Print Name__________________________________ Date_______________________________

Please Mail Application to: PUC, PO Box 2148, Salem OR 97308

or Fax to: 1-877-567-1977 or 503-378-6047

Do you have questions? Call us at 1-800-848-4442 or 503-373-7171

2	PUC Form FM784 (5/12) ENG

The Oregon Public Utility Commission (PUC) manages the Oregon Telephone Assistance Program (OTAP), also known as Lifeline. If you qualify, this federal and state government assistance program reduces your monthly phone bill by $12.75.

You may qualify if you participate in one of the following programs:

Supplemental Nutrition Assistance Program; Food Stamps (SNAP)

Supplemental Security Income (SSI)

Temporary Assistance for Needy Families (TANF)

National School Lunch Program; Free Lunch Program Only (NSLP)

Certain State Medical Programs or Certain Medicaid Programs at or below 135% of the federal poverty guidelines

Landline phone companies that provide the OTAP/Lifeline benefit:

Asotin	Frontier	Nehalem	Roome Tel Com
Beaver Creek	Gervais	North State	Scio Mutual
Canby Co-Op	Helix	Oregon Tel. Corp.	St. Paul
CenturyLink	Home/TDS	Oregon/Idaho	Stayton Co.
Clear Creek	Molalla	People’s	Warm Springs
Colton	Monitor	Pine Telephone
ComSpan	Monroe	Pioneer
Eagle	Mt. Angel	Reliance Connects

Wireless phone companies that provide the OTAP/Lifeline benefit:

AT&T Mobility* -in select areas	Cricket	Snake River PCS	US Cellular

The OTAP/Lifeline benefit cannot be applied to Pay-As-You-Go Plans.

*AT&T Mobility only offers the OTAP/Lifeline benefit in select areas.

Call 1-800-377-9450 to determine if the OTAP/Lifeline benefit is offered in your coverage area.

3	PUC Form FM784 (5/12) ENG