Sprint Lifeline Form – Fill Out and Use This PDF

1.APPLICANT INFORMATION: (PLEASE PRINT) THE PERSON BELOW MUST BE THE SAME PERSON APPLYING FOR THE DISCOUNT

Last Name	First Name		Middle Name or Initial
Home Telephone Number (if applicable)	Date of Birth		Social Security Number
(_______) ________ – _______________	________ / _______ / ________		________ - ______ - __________
	mm/dd/yyyy		9-digits
HOME ADDRESS:	IS THIS A TEMPORARY ADDRESS?	

Street/Apartment No. (Sorry, P.O. Box numbers cannot be accepted)

City	State	Zip Code
MAILING/BILLING ADDRESS: (IF DIFFERENT FROM ABOVE)
	Street/Apartment No.
City	State	Zip Code

2.EXISTING SERVICE: (CHECK ALL THAT APPLY)

No, I am not a current Sprint subscriber.  Please send me a wireless phone. I understand the cost of my phone will be charged to my account.

Yes, I am a current Sprint subscriber. Existing Sprint subscribers: Current Sprint number (including area code):

(________) _________ – ________________

3.PROGRAM-BASED ELIGIBILITY (CHECK ALL PROGRAMS THAT YOU OR A HOUSEHOLD MEMBER IS CURRENTLY ENROLLED IN.)

I, or a member of my household who qualifies as my dependent for federal income tax purposes, or who I am financially responsible for, am/is eligible to receive:

 Medicaid	 Low-Income Home Energy Assistance (LIHEAP)
Supplemental Nutrition Assistance Program (SNAP) / Food Stamps	 Health Benefit Coverage Under Child Health Plan
 Supplemental Security Income (SSI)	(CHIP)
 Federal Public Housing Assistance (Section 8)

IMPORTANT: YOU MUST PROVIDE PROOF OF YOUR PROGRAM PARTICIPATION.

This could include a copy of your benefit ID card, a copy of an eligibility letter from an authorized agency or current or prior year’s statement of benefits. (DO NOT SEND ORIGINAL DOCUMENTS.)

YOU MUST COMPLETE SECTION 3 OR SECTION 4

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APPLICATION FORM – LIFELINE ASSISTANCE PROGRAM

(Please Read All Instructions Before Completing)

4.INCOME-BASED ELIGIBILITY: Calculate TOTAL household income by reporting the income of all adult persons residing in your home in the appropriate category.

IMPORTANT: YOU MUST PROVIDE PROOF OF INCOME (DO NOT SEND ORIGINAL DOCUMENTS.)

5.ACCOUNT SPENDING LIMIT (PROVIDED UPON REQUEST AT NO ADDITIONAL CHARGE)

I elect to have an account spending limit of $75 per month or less. (By electing an account spending limit of $ 75 per month or less, you will not be required to pay a service deposit to initiate Lifeline service.)

6.APPLICANT CERTIFICATION AND SIGNATURE

By signing below, I certify under penalty of perjury that the information contained within this application is true and correct to the best of my knowledge. I understand that providing false or fraudulent information to receive Lifeline benefits is punishable by law.

•I understand that Lifeline is a federal government benefit program and that willfully making a false statement or providing fraudulent

documentation in order to obtain this government benefit may result in fines, imprisonment, de-enrollment or permanent removal from the program.

•I understand that only one Lifeline discounted service (landline or wireless) 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 is not permitted to receive Lifeline benefits from multiple providers. I understand that violation of the one-per- household rule constitutes of violation of federal rules and will result in de-enrollment from the Lifeline program and potential prosecution by the United States government.

•I understand that Lifeline is a non-transferable benefit. I will not transfer to any third party, including another eligible individual, any of the rights or benefits received under the Sprint service.

•I certify that I participate in a qualifying federal program or meet the income qualifications to establish eligibility for Lifeline. I have Provided documentation as proof of eligibility, if required in Section 3 or Section 4.

•I certify that my household will receive only one Lifeline benefit. To the best of my knowledge, (i) my household is not already receiving a Lifeline benefit, or (ii) if I currently have a Lifeline Assistance plan with a different phone service provider, and if I am approved for Sprint service, I will notify my current provider that I am receiving a federal Lifeline Assistance benefit from Sprint.

•I certify that if I have provided a temporary address, Sprint may attempt to verify every 90 days that I continue to rely on that address, and I must notify Sprint within 30 days of any change of address. If I don’t respond to Sprint’s address verification attempts within 30 days, I may be de-enrolled from Sprint Lifeline service.

•I certify that I will inform Sprint within 30 days of any of the following, and may be subject to penalties if I fail to do so:

-If I move to a new address, I agree to provide that new address to Sprint.

-I no longer participate in a qualifying program or my annual household income exceeds 135% of the Federal Poverty Guidelines.

-I become aware that my household is receiving more than one Lifeline benefit.

-For any other reason, I no longer meet the criteria for federal Lifeline support.

•I authorize Sprint or its agent to access any records (including financial records) required to verify my statements herein and to confirm my eligibility for Sprint Lifeline service. I authorize state or federal agency representatives to discuss with, and/ or provide information to Sprint verifying my participation in public assistance programs that qualify me for Sprint Lifeline service.

•I authorize Sprint to provide access to or release any records required for the administration of Sprint Lifeline service.

•I understand that the completion of this application does not constitute immediate approval for Sprint Lifeline service.

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APPLICATION FORM – LIFELINE ASSISTANCE PROGRAM

(Please Read All Instructions Before Completing)

YOU MUST INITIAL THE FOLLOWING STATEMENTS BELOW:

_____ No one in my household is receiving Lifeline benefits from another provider to my knowledge.

_____ I understand that I may be required to re-certify continued eligibility for Lifeline at any time, and that failure to do so will

result in the termination of my Lifeline benefits.

_____ I consent to have my personal identification information, including name, telephone number, and address shared with the

Universal Service Administrative Company (USAC) (the Lifeline Program administrator) and/or it agents for the purpose of confirming that neither I nor my household receive more than one Lifeline benefit.

PLEASE RETURN COMPLETED APPLICATION AND

SUPPORTING DOCUMENTATION TO:

SPRINT LIFELINE ASSISTANCE PROGRAM

ACS

2432 FORTUNE DRIVE

LEXINGTON, KY 40509

OR

FAX TO: 1-859-389-4511

QUESTIONS? PLEASE CALL 1-888-408-3306

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APPLICATION FORM – LIFELINE ASSISTANCE PROGRAM

(Please Read All Instructions Before Completing)

SPRINT LIFELINE ASSISTANCE PROGRAM

LIFELINE

∙Eligible subscribers pay $15.49 per month for Lifeline service from Sprint, which is a discount off the current $29.99 monthly recurring charge (MRC). Lifeline subscribers may purchase a reduced-cost Lifeline phone.

∙Lifeline service includes 200 Anytime Minutes and Unlimited Night and Weekend Minutes, which may be used for local or long-distance calls. (Night and weekend minutes may be used before 7:00 am and after 9:00 pm Monday through Friday, and all day Saturday and Sunday.) Lifeline service also includes Voice Mail, Call Waiting, Caller ID, Numeric Paging, Roaming and Three-Way Calling at no additional charge. Call forwarding is 20¢ per minute. Roaming not included in Sprint Affiliate territories.

∙Lifeline service is only available in limited geographic areas. Lifeline assistance is only available for one wireline or

wireless phone line per household. Data services and other enhanced services or features, international long distance and access to “900” numbers are not available to Lifeline subscribers.

∙A charge of 45¢ per minute applies to usage in addition to the amounts included in the plan.

∙Lifeline service plan minutes are only available for calls within Sprint coverage areas – coverage maps are available at www.sprint.com, or at any Sprint retail location. Off-network roaming calls in Sprint Affiliate territories are 45¢ per minute.

∙Lifeline service from Sprint is subject to the terms and conditions included in your Subscriber Agreement. Lifeline service is subject to a minimum two-year term. If you are already a current Sprint subscriber, your existing calling plan will be terminated and you will be placed on a Lifeline service plan. You will be eligible for Lifeline service only if your account is in good standing and no payments are past due.

∙Other restrictions may apply.

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