Fillable 43390 New OPUC Oregon Lifeline App V3.indd

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43390 New OPUC Oregon Lifeline App V3.indd

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Only fill this section out if you are applying through a child or dependent.
Full legal name
/ /
First Middle
Last
Phone number Date of birth
Month Day Year
Email address
Social Security Number
(
SSN
)
@
– –
Home address
(The address where you will get service. Do not use a P.O. Box)
Apt., Unit, etc.
City State Zip Code
Oregon
Mailing address (if di erent than home address)
Apt., Unit, etc.
?sserdda yraropmet a siht sI
seY N o
Their full legal name
Their date of birth
Month Day Year
– –
City State Zip Code
First Middle
Last
Their full Social Security Number (SSN)
/ /
––
Full legal name
Date of birth
Social Security Number
(
SSN
)
Home address
?sserdda yraropmet a siht sI
City Zip Code
Oregon Lifeline Application
Oregon Lifeline is a federal and state government program that lowers the monthly cost of
phone or internet service for qualifying low-income households.
If you qualify (see page 2), complete sections 1 though 5 and submit it to the service provider of
your choice on page 4.
PLEASE CONTINUE TO PAGE 2
PAGE 1
1
Your Information - Please print clearly.
All highlighted fields are required.
ENG 1 28 2020
OR999999999999XB
Place a check mark next to the program that qualifies you.
Supplemental Nutrition Assistance Program (SNAP)
Supplemental Security Income (SSI)
Medicaid
Veterans or Survivor’s Pension Benefit
Federal Public Housing Assistance (Section 8)
2
✔
Complete Section 2b ONLY if you do not qualify for any programs in Section 2a.
Place a check mark
next to your Household Size. To qualify, your Household Yearly
Income must fall within the range indicated next to your Household Size. A Household is
defined as any individual or group of individuals who live together at the same address
and share income and expenses. Proof of income must be included with your application.
✔
• Last year’s Federal or State income tax return
• Current annual income statement from employer
• Pay stubs for any three consecutive months within the last 12 months
• Veteran’s Administration statement of benefits
• Unemployment or Workers’ Compensation statement of benefits
• Social Security statement of benefits
• Retirement or Pension statement of benefits
• Divorce decree or Child Support documentation containing income information
a
For each additional household member above 6, add $6,048.
Provide a copy of one or more of the following documents as proof of your income:
Gross Gross
Household Yearly
Size Income
1
2
7,226
3,274
Household Yearly
Size Income
3
4
9,322
5,370
Household Yearly
Size Income
5
6
1,418
7,466
Gross
PLEASE CONTINUE TO PAGE 3
PAGE 2
or
Eligibility – Choose how you qualify for Lifeline.
2
b
}
Eligibility documentation not required.
Access and enTouch Wireless require
proof of identity.
}
Eligibility documentation required.
Proof of identity required.
}
Proof of identity
required.
ENG 1 28 2020
OR999999999999XB
PLEASE CONTINUE TO PAGE 4
PAGE 3
Agreement
I agree, under penalty of perjury, to the following statements:
You must initial next to each statement.
I understand that completing this application does not immediately approve me for the Oregon Lifeline benefit.
I will be notified in writing of my application status.
I know that my household can only get one Lifeline benefit and, to the best of my knowledge, my household is not
getting more than one Lifeline benefit.
• A household is defined as any persons who live together at the same address and share income and expenses.
I agree that my service provider can give the Oregon Public Utility Commission, the Federal Communications
Commission (FCC), and the Universal Service Administrative Company (USAC) all of the information I am giving on thi
s
form. I understand that this information is meant to help run the Lifeline Program and that if I do not give it, I will not
be able to get Lifeline benefits.
I understand that my Oregon Lifeline benefit may not be transferred or given to another person.
I agree that if I move, I will give my service provider my new address within 30 days.
I understand that I have to tell my service provider within 30 days if I do not qualify for Lifeline anymore, including:
1) I, or the person in my household that qualifies, do not qualify through a government program or income anymore
.
2 ) E i t h er I or someone in my household gets more than one Lifeline benefit (including, more than one Lifeline
broadband internet service, more than one Lifeline telephone service, or both Lifeline telephone and Lifeline
broadband internet services).
The Oregon Public Utility Commission may have to check whether I still qualify at any time. If I need to recertify
(renew) my Lifeline benefit, I understand that I have to respond by the deadline or I will be removed from the Lifeline
Program and my Lifeline benefit will stop.
I know that willingly giving false or fraudulent information to get Lifeline Program benefits is punishable by law and
can result in fines, jail time, de-enrollment, or being barred from the program.
All the information and agreements that I provided on this form are true and correct to the best of my knowledge.
3
Applicant Signature:
Print Name:
Agent’s full legal name
First Middle
Last
Agent’s ID number Agent’s date of birth
/ /
Month Day Year
4
Agent Information
Answer only if a sales person submits this form.
Date:
/ /
Month Day Year
1/28/2020
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Initial
OR999999999999XB
PAGE 4
Access Wireless
•
•
•
Access Wireless
One Levee Way, Ste 3116
Newport, KY 41071
•
Assurance Wireless
•
•
•
Assurance Wireless
PO Box 5040
Charelston, IL 61920-9907
—or—
•
—or—
•
enTouch Wireless
•
•
•
enTouch Wireless
955 Kacena Rd, Ste A
Hiawatha, IA 52233
•
Service Provider
5
If you qualify, you’ll need an Account PIN to access your account
and a Secret Answer in case you ever forget your PIN.
Please write them down for safekeeping.
CHOOSE YOUR ACCOUNT PIN:
• It must be 6 numbers long
• No more than 3 consecutive numbers in a row (1234 won’t work)
• Do not repeat numbers next to each other (44 won’t work)
• No symbols or letters (@#PRTE won’t work)
FOR YOUR SECURITY WITH ASSURANCE WIRELESS
YOUR SECRET ANSWER:
What is your favorite city?
Your Secret Answer: _________________________________
YOUR ACOUNT PIN:
*Proof of identity can include your driver’s license, U.S. Government, Military, or state issued ID.
•Place a check mark ■✔ next to the service provider of your choice.
•Include with your application a copy of your eligibility documentation and proof of
identity,* if required. See section 2a or 2b
ENG 1 28/2020
OR999999999999XB
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43390 New OPUC Oregon Lifeline App V3.indd

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Completed 19 July 2020

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