Tribal Link Up Program: Tribal Link Up provides eligible subscribers with a reduction of up to $30 for connection charges for basic home telephone or broadband service. Deferred payments of connection charges, without interest, may be arranged for Tribal Link Up subscribers. Tribal Lifeline Program: Tribal Lifeline support may reduce an eligible subscriber s basic local residential telephone rate by $26.45 per month. Tribal Lifeline subscribers may also receive long distance blocking on their telephone without charges. Or alternate credits for qualifying Internet service: Tribal Lifeline can provide a monthly discount of up to $34.25 off of the cost of qualifying broadband internet access service. Application Instructions: Verify that you may participate in either of these programs by reviewing the lists of qualifications shown below. If you do qualify, please complete the application form, include proof of eligibility document(s), and send all documents to: Eastern Nebraska Telephone Company P.O. Box 400 Blair, NE 68008 Qualifications: People who are currently participating in at least one of the following programs would qualify for the Tribal Link Up and/or Tribal Lifeline support assistance: Medicaid (e.g., Title XIX/Medical, State Supplemental Assistance) Supplemental Nutrition Assistance Program (SNAP, formerly known as Food Stamps) Food Distribution Program on Indian Reservations (FDPIR) Supplemental Security Income (SSI) Federal Public Housing Assistance (Section 8) Veterans Pension and Survivors Benefit Bureau of Indian Affairs General Assistance Tribally-Administered Temporary Assistance for Needy Families (TTANF) Head Start Income is at or below 135% of the Federal Poverty Guidelines Tribal lands are defined as any federally-recognized Indian tribe s reservation, pueblo or colony; Indian allotments; and areas that fall outside the boundaries of existing Tribal lands but have been designated by the Federal Communications Commission as Tribal Lands for the purpose of receiving the Tribal Lands Lifeline and Tribal Link Up support.
Name (Last) (First) (Middle) Residential Address (Do not use a P.O. Box) (Street) (Apt. #) (City) (State) (Zip Code) Please check one: Is the address listed above: ( ) Temporary ( ) Permanent Billing Address (If different than residential address. A P.O. Box may be used) (Street) (Apt. #) (City) (State) (Zip Code) Social Security Number (last 4 digits): OR Tribal ID Number: Date of Birth: Telephone Number (if you have existing service) Telephone Number where you can be reached for messages Please answer the following questions (check all that apply): 1. I am applying for: ( ) Tribal Lifeline monthly telephone service discount ( ) Tribal Link Up telephone connection charge discount 2. I am applying as an individual living on tribal lands : ( ) Yes ( ) No 3. I, one or more of my dependents, or my household currently receive assistance benefits form at least one of the following programs: a. Name of person(s) receiving benefits: b. Receiving assistance benefits through: Medicaid (e.g., Title XIX/Medical, State Supplemental Assistance Supplemental Nutrition Assistance Program (SNAP, formerly known as Food Stamps) Food Distribution Program on Indian Reservations (FDPIR) Supplemental Security Income (SSI) Federal Public Housing Assistance (Section 8) Veterans Pension and Survivor Benefit Bureau of Indian Affairs General Assistance Tribally-Administered Temporary Assistance for Needy Families (TTANF) Head Start OR My household income is at or below 135% of the Federal Poverty Guidelines. Number of individuals in my household:
Lifeline Eligibility Based On Income Guidelines To qualify due to your annual household income being at or below 135% of the poverty level, use the following guidelines. Income is all income received by all members of a household. This includes, but is not limited to: salary before deductions of taxes, public assistance benefits, social security payments, pensions, unemployment compensation, veterans benefits, inheritances, alimony, child support payments, workers compensation benefits, gifts, and lottery winnings. On the left side of the table below find the number of people in your household. If annual income of your household falls at or below the total listed to the right of the number of people in your household you are eligible for Lifeline. You must provide copies of documentation to show that your annual income is at or below 135% of the poverty level. Below is a list of documents accepted to show proof of income. When submitting documentation, please do not submit a document that is over one calendar year old. If possible, please send a copy of the documents you are submitting. Submitted documents will not be returned. Salaries, Wages, Tips, Commissions, etc.: Three consecutive months of paystubs, your most recent W2 forms or last year s income tax form. If you are self-employed; send a copy of your recent income tax return. Retirement, Social Security or Pensions: Copy of your award notice or statement of benefits letter. Workers Compensation, Unemployment or Disability: Copy of the letter you received from Workers Compensation, letter from State employment office, check stubs or your award letter from the Social Security Office. Military Benefits: Copy of your Veterans, Civil Service, or Military Allotment benefits statement. Child Support or Alimony: Copy of checks received, court decree or legal agreement. Other: Any award letters or benefit statements of other income received. Household has no income: If your household does not have any income, you are required to submit a written statement which clearly states that your household has no income. Your statement must be signed and dated by you, the applicant and be included with the application you return to Eastern Nebraska Telephone Co. Number of members in your household Annual Income 1 $16,389 2 $22,221 3 $28,053 4 $33,885 5 $39,717 6 $45,549 7 $51,381 8 $57,213 For each additional person, add $5,832
Important Information on the Tribal Lifeline and Tribal Link Up Support Programs You are required to provide documentation of eligibility. Tribal Lands Lifeline and Tribal Link Up are federal government assistance benefits and willfully making false statements to obtain the benefits can result in fines, imprisonment, de-enrollment, or being barred from the programs. Only one Lifeline service is available per household. A household is defined, for the purposes of the Lifeline program, as any individual or group of individuals who live together at the same address as one economic unit. An economic unit consists of all adult individuals contributing to and sharing in the income and expenses of a household. A household may include related and unrelated persons. A household is not permitted to receive Lifeline benefits from multiple providers. Violation of the one-perhousehold limitation constitutes a violation of the Federal Communications Commission s rules and will result in your de-enrollment from the program. Lifeline is a non-transferable benefit and you may not transfer your benefit to any other person. I certify, under penalty of perjury, that: (1) I meet the income-based or program-based eligibility criteria for receiving Lifeline, provided in 47 C.F.R. 54.409. I have provided documentation of eligibility; (2) I will notify the carrier 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 criteria for receiving Lifeline support, I am receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline benefit; (3) If I am seeking to qualify for Lifeline as an eligible resident of Tribal lands, I live on Tribal lands, as defined in 47 C.F.R 54.400(e); (4) If I move to a new address, I will provide that new address to the telephone company within 30 days; (5) If I provided a temporary residential address to the telephone company, I will be required to verify my temporary residential address every 90 days; (6) My household will receive only one Lifeline service and, to the best of my knowledge, my household is not already receiving a Lifeline service; (7) 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 will result in de-enrollment and the termination of my Lifeline benefits pursuant to 47 C.F.R. 54.405(e)(4); (8) I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law; and (9) The information contained in this application and certification form is true and correct to the best of my knowledge.
I acknowledge and consent to American Broadband providing my Tribal Lifeline subscriber information, including, but not limited to, my name, residential address, date of birth, the last four digits of my Social Security number and/or Tribal Identification number, the telephone number associated with the Tribal Lifeline service, the Tribal Lifeline service initiation date, and the program and/or income eligibility means for which I qualified for Tribal Lifeline to the National Lifeline Accountability Database to ensure proper administration of the Tribal Lifeline Program. I understand that failure to provide consent will result in denial of or de-enrollment from the Tribal Lifeline Program. Signature Date (Send completed applications to the Eastern Nebraska Telephone Company, P.O. Box 400, Blair, NE 68008) For Office Use Only: Documentation Reviewed: Expiration Date of Document: Method Documentation was Provided: Program Participant Name: Date Reviewed: Employee Name or ID: