PLEASE CONTINUE TO PAGE 4
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 this
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) Either 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.
Agent’s full legal name
Agent’s ID number Agent’s date of birth
Month Day Year
Answer only if a sales person submits this form.
Month Day Year