SNAP (Fd Stamps) The Supplemental Nutritin Assistance Prgram (SNAP) used t be called Fd Stamps. Yu can shw yur SNAP card r shw an award letter that has: Name f the prgram Name f the participant Address f the participant Date f the award Yur state might use a different name fr SNAP. Lk it up n this list f SNAP names by state. Medicaid Each state has its wn Medicaid prgram and card. Yur card shuld have: Name f the prgram Name f the participant Yur state might use a different name fr Medicaid. Lk it up n this list f Medicaid names by state. Supplemental Security Incme (SSI) Sme states ffer SSI, but yu can nly use federal SSI t sign up fr Lifeline. Yur award letter (frm the U.S. Scial Security Administratin) shuld have the fllwing infrmatin: Name f the prgram Name f the participant Address f the participant Date f the award Award amunt Yu can als use a check stub frm the U.S. Scial Security Administratin if it includes the date and the participant's name.
Federal Public Husing Assistance (FPHA) Sme states ffer husing assistance, but yu can nly use Federal Public Husing Assistance (FPHA) t sign up fr Lifeline. If yu use FPHA, shw ne f these: 1. Award letter that has: Name f the prgram Date f the award Name f the participant Award amunt 2. Public Husing Assistance lease agreement that has: The type f Public Husing Assistance credit used If yu d nt have these items, cntact the agency that apprved yur public husing applicatin and ask fr frmal dcumentatin f the award. Find their cntact infrmatin n the U.S. Department f Husing and Urban Develpment's (HUD) state cntact and agency listing.
Veterans Pensin r Survivrs Benefit Sme states ffer a Veterans Pensin, but yu can nly use the federal Veterans Pensin (and federal Survivrs Pensin) t sign up fr Lifeline. If yu receive a federal pensin, shw ne f these: 1. Pensin Grant Letter that has: The participant's name The participant's address A decisin abut the mnthly entitlement amunt Payment start date 2. Cst f Living Adjustment (COLA) Letter that has: Mnthly/quarterly/semi-annual/annual payment rate Effective date 3. Survivrs Benefit Summary Letter that has: Survivrs claim number The related veteran's name Mnthly award amunt
Tribal Prgrams T qualify fr Tribal Lifeline, yu must shw that yu reside n Tribal lands and participate in ne f the federal r state assistance prgrams listed abve r ne f these benefit prgrams: Bureau f Indian Affairs (BIA) General Assistance Shw an award letter frm the natinal r reginal BIA ffice. Yu can als shw a check stub frm the BIA if it includes the date, name f the participant, and that the benefit received is BIA General Assistance. Tribally-Administered Temprary Assistance fr Needy Families (TANF) Shw an award letter that has: Name f the prgram Name f the participant Address f the participant Date f the award Tribal Head Start Yu can nly qualify thrugh the Tribal Head Start Prgram if yu qualified fr it thrugh yur incme. Shw a letter that includes the name f the child wh participates. Fd Distributin Prgram n Indian Reservatins (FDPIR) Shw an award letter frm an Indian Tribal Organizatin (ITO) r anther state agency. All award letters r ther fficial dcuments shuld have: Name f the participant The start and end dates f the award perid The telephne number f the Fd Distributin Prgram ffice and the name and address f the persn t cntact fr additinal infrmatin Valid dcumentatin f participatin in the FDPIR is: Award letter that states eligibility fr FDPIR benefits A benefit card r cpy f benefit card
111.,. Universal Service I Administrative C. 2017 Federal Pverty Guidelines - 135% T,,.....- - --- ---, --., -.,. L,:-;.. ~:.t.. ---''!!Z" ~.;?J-L,...-n~---:,._ '"; 7~---. ~,, - ' -:. -,-... -=:-. ;:--._- :-: ~;""' _;, ~-;;::--,.,----- ;-,- -,:; - :.. : 48Cntiguus..,'" :...,, :,... ', Husehld Size. States, D.c: and.. Alaska.... ' ~ -.. Hawaii...,.. -...._- }~i:_ritri.~~:,:. -..... ----a_ :_:~:~~---~:---:,...:..:..: 1 $16,281 $20,331 $18,711 2 $21,924 $27,392 $25,205 3 $27,567 $34,452 $31,698 4 $33,210 $41,513 $38,192 5 $38,853 $48,573 $44,685 6 $44,496 $55,634 $51,179 7 $50,139 $62,694 $57,672 8 $55,782 $69,755 $64,166 Fr each additinal persn, add $5,643 $7,061 $6,494 Please nte: Su rce: Federal Register, Vl. 82, N. 19, January 31, 2017, pp. 8831-8832 The federal pverty guidelines are typically updated at the end f January. universalservice.rg
INCOME ELIGIBILITY An applicant may be eligible fr Lifeline Prgram-supprted service if he r she has a husehld incme at r belw 135 percent f the federal pverty guidelines. Read the federal pverty guidelines c;:a t learn mre. If an applicant claims eligibility based n incme, an eligible telecmmunicatins carrier (ETC) must review dcumentatin that demnstrates the husehld's incme. If the ETC has access t a database that cntains infrmatin t cnfirm the husehld's incme, the ETC must use the database t validate the husehld's incme. If there is n database available, the ETC must review dcumentatin that demnstrates the husehld's incme. The FCC has deemed the fllwing as acceptable dcumentatin f incme (47 C.F.R. Sectin 54.41 O(b )( 1 )(i)(b): The prir year's state, federal, r Tribal tax return; Current incme statement frm an emplyer r paycheck stub; Scial Security statement f benefits; Veterans Administratin statement f benefits; Retirement r pensin statement f benefits; Unemplyment r Wrkers' Cmpensatin statement f benefits; Federal r Tribal ntice letter f participatin in General Assistance; and Divrce decree, child supprt award, r ther fficial dcument cntaining incme infrmatin. If the dcumentatin des nt cver a full year, such as a current pay stub, the subscriber must present the same type f dcumentatin cvering three cnsecutive mnths within the previus 12 mnths.
Lifeline Prgram Husehld Wrksheet Abut Lifeline Lifeline is a benefit that lwers the mnthly cst f phne r internet service (nt bth). Yu are nly allwed t get ne Lifeline benefit per husehld, nt per persn. What this wrksheet is fr Use this wrksheet if smene else at yur address gets Lifeline. The answers t these questins will help yu find ut if there is mre than ne husehld at yur address. What is a husehld? A husehld is a grup f peple wh live tgether and share incme and expenses (even if they are nt related t each ther). Examples f ne husehld: A married cuple wh live tgether are ne husehld. They must share ne Lifeline benefit. A parent/guardian and child wh live tgether are ne husehld. They must share ne Lifeline benefit. An adult wh lives with friends r family wh financially supprt him/her are ne husehld. They must share ne Lifeline benefit. Examples f mre than ne husehld: 4 rmmates wh live tgether but d nt share mney are 4 husehlds. They can have ne Lifeline benefit each, 4 ttal. 30 senirs wh live in an assisted-living hme are 30 husehlds. They can have ne Lifeline benefit each, 30 ttal. Husehld expenses A husehld shares expenses. Husehld expenses include, but are nt limited t, fd, healthcare expenses, and the cst f renting r paying a mrtgage n yur place f residence and utilities. Incme Husehlds share incme. Incme includes salary, public assistance benefits, scial security payments, pensins, unemplyment cmpensatin, veteran s benefits, inheritances, alimny, child supprt payments, wrker s cmpensatin benefits, gifts, and lttery winnings. Page 1 f 3 Universal Service Administrative Cmpany www.usac.rg
Lifeline Prgram Husehld Wrksheet What is yur full legal name? The name yu use n fficial dcuments, like yur Scial Security Card r State ID. Nt a nickname. First Last Middle (ptinal) Suffix What is yur mailing address? (Only fill this ut if it is nt the same as yur hme address.) Street Number and Name Apt., Unit, etc. City State Zip Can yu apply? Fllw this decisin tree t cnfirm if yu qualify fr the Lifeline Prgram. 1. D yu live with anther adult? Adults are peple wh are 18 years ld r lder, r wh are emancipated minrs. This can include a spuse, dmestic partner, parent, adult sn r daughter, adult in yur family, adult rmmate, etc. Yes If yes, answer questin 2 2. D they get Lifeline? Yes If yes, answer questin 3 N N Yu can apply fr Lifeline. Yu live in a husehld that des nt get Lifeline yet. Please initial line B n page 3, and sign and date the wrksheet. Check this bx 3. D yu share mney (incme and expenses) with them? This can be the cst f bills, fd, etc., and incme. If yu are married, yu shuld check yes fr this questin. Yes N Yu can apply fr Lifeline. Yu live at an address with mre than ne husehld and yur husehld des nt get Lifeline yet. Please initial lines A and B n page 3, and sign and date the wrksheet. Yu d nt qualify fr Lifeline because smene in yur husehld already gets the benefit. Yu are nly allwed t get ne Lifeline discunt per husehld, nt per persn. Check this bx Check this bx Page 2 f 3 Universal Service Administrative Cmpany www.usac.rg
Lifeline Prgram Husehld Wrksheet Agreement Please initial the agreement belw and sign and date this wrksheet. Submit this wrksheet t yur service prvider with yur Lifeline Prgram Applicatin Frm. Signature Ntice A I live at an address with mre than ne husehld. B I understand that the ne-per-husehld limit is a Federal Cmmunicatins Cmmissin (FCC) rule and I will lse my Lifeline benefit if I break this rule. Tday s Date PRIVACY ACT STATEMENT: The Privacy Act is a law that requires the Federal Cmmunicatins Cmmissin (FCC) and the Universal Service Administrative Cmpany (USAC) t explain why we are asking individuals fr persnal infrmatin and what we are ging t d with this infrmatin after we cllect it. Authrity: Sectin 254 f the Cmmunicatins Act (47 U.S.C. 254), as amended, 47 U.S.C. 254, authrizes the FCC t perate the Lifeline prgram. Using this authrity, the FCC has designated USAC as the permanent Lifeline Administratr. The FCC has published rules detailing hw cnsumers can qualify fr Lifeline services and what Lifeline services they may receive (47 CFR 54.400 et seq.). Purpse: We are cllecting this persnal infrmatin s we can verify that yu qualify fr the Lifeline prgram and s we can efficiently prvide Lifeline services t yu. We access, maintain and use yur persnal infrmatin in the manner described in the Lifeline System f Recrds Ntice (SORN), FCC/WCB-1, which we have published in 82 Fed. Reg. 38686 (Aug. 15, 2017). Rutine Uses: We may share the persnal infrmatin yu enter int this frm with ther parties fr specific purpses, such as: with cntractrs that help us perate the Lifeline prgram; with ther federal and state gvernment agencies that help us determine yur Lifeline eligibility; with the telecmmunicatins cmpanies that prvide yu Lifeline service; and with law enfrcement and ther fficials investigating ptential vilatins f Lifeline rules. A cmplete listing f the ways we may use yur infrmatin is published in the Lifeline SORN described in the Purpse paragraph f this statement. Disclsure: Yu are nt required t prvide the infrmatin we are requesting, but if yu d nt, yu will nt be eligible t receive Lifeline services under the Lifeline Prgram rules, 47 C.F.R. 54.400-54.423. Page 3 f 3 Universal Service Administrative Cmpany www.usac.rg
Lifeline Prgram Applicatin Frm 1. Abut Lifeline Lifeline is a federal benefit that lwers the mnthly cst f phne r internet service. Rules If yu qualify, yur husehld can get Lifeline fr phne r internet service, but nt bth. If yu get Lifeline fr phne service, yu can get the benefit fr ne mbile phne r ne hme phne, but nt bth. If yu get Lifeline fr internet service, yu can get the benefit fr yur mbile phne r yur hme cnnectin, but nt bth. If yu get Lifeline fr bundled phne and internet service, yu can get the benefit fr yur mbile phne bundled service r yur hme bundled service, but nt bth. Yur husehld cannt get Lifeline frm mre than ne phne r internet cmpany. Yu are nly allwed t get ne Lifeline benefit per husehld, nt per persn. If mre than ne persn in yur husehld gets Lifeline, yu are breaking the FCC s rules and will lse yur benefit. What is a husehld? A husehld is a grup f peple wh live tgether and share incme and expenses (even if they are nt related t each ther). D nt give yur benefit t anther persn Lifeline is nn-transferable. Yu cannt give yur Lifeline benefit t anther persn, even if they qualify. Be hnest n this frm Yu must give accurate and true infrmatin n this frm and n all Lifeline-related frms r questinnaires. If yu give false r fraudulent infrmatin, yu will lse yur Lifeline benefit (i.e., de-enrllment r being barred frm the prgram) and the United States gvernment can take legal actins against yu. This may include (but is nt limited t) fines r imprisnment. Yu may need t shw ther dcuments If the Lifeline Prgram Administratr is nt able t prve yu r smene in yur husehld qualify using this frm and electrnic databases, yu may need t shw an fficial dcument frm ne f the gvernment qualifying prgrams r t prve yur annual incme. Yu can submit cpies f yur fficial dcuments with this applicatin r wait until the Lifeline Prgram Administratr asks yu fr them. T add them nw, include the dcuments in ptin 1 r ptin 2 belw: 1. If yu qualify thrugh a gvernment prgram: cpies f bth sides f yur state ID card and an fficial dcument frm the prgrams yu are qualifying thugh (yur SNAP card, Medicaid card, etc.) 2. If yu qualify thrugh yur incme: cpies f bth sides f yur state ID card and 3 pay stubs in a rw (r ther accepted dcuments). Visit lifelinesupprt.rg t see the full list f accepted dcuments. Apply Bring r mail the frm t this address: T apply fr a Lifeline benefit, fill ut every sectin f this frm, initial every agreement statement, and sign the last page. Page 1 f 5 Universal Service Administrative Cmpany www.usac.rg
Lifeline Prgram Applicatin Frm 2. Yur Infrmatin All fields are required unless indicated. What is yur full legal name? The name yu use n fficial dcuments, like yur Scial Security Card r State ID. Nt a nickname. First Last Middle (ptinal) What is yur phne number (if yu have ne)? What is yur email address (if yu have ne)? What is yur date f birth? Mnth Day Year Suffix (ptinal) What are the last 4 numbers f yur Scial Security Number (SSN)? (Enter yur Tribal Identificatin Number if yu d nt have a SSN) What is the best way t reach yu? email phne text message mail * Tribal lands include any federally recgnized Indian tribe s reservatin, puebl, r clny, including frmer reservatins in Oklahma; Alaska Native regins established pursuant t the Alaska Native Claims Settlement Act (85 Stat. 688); Indian alltments; Hawaiian Hme Lands areas held in trust fr Native Hawaiians by the state f Hawaii, pursuant t the Hawaiian Hmes Cmmissin Act, 1920 July 9, 1921, 42 Stat. 108, et. seq., as amended; and any land designated as such by the Cmmissin fr purpses f this subpart pursuant t the designatin prcess in the FCC s Lifeline rules. What is yur hme address? (The address where yu will get service. D nt use a P.O. Bx) Street Number and Name Apt., Unit, etc. City State Zip Is this a temprary address? Yes N Check if yu live n Tribal Lands* What is yur mailing address? (Only fill this ut if it is nt the same as yur hme address.) Street Number and Name Apt., Unit, etc. City State Zip Only fill this sectin ut if yu are applying thrugh a child r dependent. Check if yu are qualifying thrugh a child r dependent in yur husehld. If s, answer the fllwing questins: What is their full legal name? First Last Middle (ptinal) Suffix What are the last 4 numbers f their Scial Security Number (SSN)? (Enter their Tribal Identificatin Number if they d nt have a SSN) What is their date f birth? Check if they live n Tribal Lands Mnth Day Year Page 2 f 5 Universal Service Administrative Cmpany www.usac.rg
Lifeline Prgram Applicatin Frm 3. Qualify fr Lifeline Fill ut this sectin t shw that yu, yur dependent, r smene in yur husehld qualifies fr Lifeline. Yu can qualify thrugh sme gvernment assistance prgrams r thrugh yur incme (yu d nt need t qualify thrugh bth). Qualify thrugh a gvernment prgram: Check all prgrams that yu r smene in yur husehld have: Supplemental Nutritin Assistance Prgram (SNAP) (Fd Stamps) Supplemental Security Incme (SSI) Medicaid Federal Public Husing Assistance (FPHA) Veterans Pensin r Survivrs Benefit Prgrams Tribal Specific Prgrams Bureau f Indian Affairs (BIA) General Assistance Tribal Temprary Assistance fr Needy Families (Tribal TANF) Fd Distributin Prgram n Indian Reservatins (FDPIR) Tribal Head Start (nly husehlds that meet the incme qualifying standard) Or Qualify thrugh yur incme: (Only fill this ut if yu d nt qualify thrugh a gvernment prgram.) Including yu, hw many peple live in yur husehld? (check ne) Is yur incme the same r less than the amunt listed fr yur state and husehld size? (nly check yes r n next t yur husehld size) All 48 States & DC (nt Alaska and Hawaii) Alaska Hawaii 1 $16,281 $20,331 $18,711 Yes N 2 $21,924 $27,392 $25,205 Yes N 3 $27,567 $34,452 $31,698 Yes N 4 $33,210 $41,513 $38,192 Yes N 5 $38,853 $48,573 $44,685 Yes N 6 $44,496 $55,634 $51,179 Yes N 7 $50,139 $62,694 $57,672 Yes N 8 $55,782 $69,755 $64,166 Yes N If mre than 8, add this amunt fr each extra persn: $5,643 $7,061 $6,494 Yes N 135% f the 2017 Federal Pverty Guidelines *The Federal Pverty Guidelines are typically updated at the end f January. Page 3 f 5 Universal Service Administrative Cmpany www.usac.rg
Lifeline Prgram Applicatin Frm 4. Agreement I agree, under penalty f perjury, t the fllwing statements: Yu must initial next t each statement. I (r my dependent r ther persn in my husehld) currently get benefits frm the gvernment prgram(s) listed n this frm r my annual husehld incme is 135% r less than the Federal Pverty Guidelines (the amunt listed in the Federal Pverty Guidelines table n this frm). I agree that if I mve I will give my service prvider my new address within 30 days. I understand that I have t tell my service prvider within 30 days if I d nt qualify fr Lifeline anymre, including: 1) I, r the persn in my husehld that qualifies, d nt qualify thrugh a gvernment prgram r incme anymre. 2) Either I r smene in my husehld gets mre than ne Lifeline benefit (including, mre than ne Lifeline bradband internet service, mre than ne Lifeline telephne service, r bth Lifeline telephne and Lifeline bradband internet services). I knw that my husehld can nly get ne Lifeline benefit and, t the best f my knwledge, my husehld is nt getting mre than ne Lifeline benefit. I agree that my service prvider can give the Lifeline Prgram administratr all f the infrmatin I am giving n this frm. I understand that this infrmatin is meant t help run the Lifeline Prgram and that if I d nt let them give it t the Administratr, I will nt be able t get Lifeline benefits. All the answers and agreements that I prvided n this frm are true and crrect t the best f my knwledge. I knw that willingly giving false r fraudulent infrmatin t get Lifeline Prgram benefits is punishable by law and can result in fines, jail time, de-enrllment, r being barred frm the prgram. My service prvider may have t check whether I still qualify at any time. If I need t recertify (renew) my Lifeline benefit, I understand that I have t respnd by the deadline r I will be remved frm the Lifeline Prgram and my Lifeline benefit will stp. I was truthful abut whether r nt I am a resident f Tribal lands, as defined in sectin 2 f this frm. Signature Tday s Date 5. Agent Infrmatin Answer nly if a sales persn submits this frm. What is the agent s full legal name? The name yu use n fficial dcuments, like yur Scial Security Card r State ID. Nt a nickname. First Last Middle (ptinal) What is the agent s USAC ID number? What is the agent s date f birth? Suffix Mnth Day Year Page 4 f 5 Universal Service Administrative Cmpany www.usac.rg
Lifeline Prgram Applicatin Frm Ntice PRIVACY ACT STATEMENT: The Privacy Act is a law that requires the Federal Cmmunicatins Cmmissin (FCC) and the Universal Service Administrative Cmpany (USAC) t explain why we are asking individuals fr persnal infrmatin and what we are ging t d with this infrmatin after we cllect it. Authrity: Sectin 254 f the Cmmunicatins Act (47 U.S.C. 254), as amended, 47 U.S.C. 254, authrizes the FCC t perate the Lifeline prgram. Using this authrity, the FCC has designated USAC as the permanent Lifeline Administratr. The FCC has published rules detailing hw cnsumers can qualify fr Lifeline services and what Lifeline services they may receive (47 CFR 54.400 et seq.). Purpse: We are cllecting this persnal infrmatin s we can verify that yu qualify fr the Lifeline prgram and s we can efficiently prvide Lifeline services t yu. We access, maintain and use yur persnal infrmatin in the manner described in the Lifeline System f Recrds Ntice (SORN), FCC/WCB-1, which we have published in 82 Fed. Reg. 38686 (Aug. 15, 2017). Rutine Uses: We may share the persnal infrmatin yu enter int this frm with ther parties fr specific purpses, such as: with cntractrs that help us perate the Lifeline prgram; with ther federal and state gvernment agencies that help us determine yur Lifeline eligibility; with the telecmmunicatins cmpanies that prvide yu Lifeline service; and with law enfrcement and ther fficials investigating ptential vilatins f Lifeline rules. A cmplete listing f the ways we may use yur infrmatin is published in the Lifeline SORN described in the Purpse paragraph f this statement. Disclsure: Yu are nt required t prvide the infrmatin we are requesting, but if yu d nt, yu will nt be eligible t receive Lifeline services under the Lifeline Prgram rules, 47 C.F.R. 54.400-54.423. Page 5 f 5 Universal Service Administrative Cmpany www.usac.rg