What this worksheet is for
Use this worksheet if someone else at your address gets Lifeline. The answers to these questions will help
you find out if there is more than one household at your address.
What is a household?
A household is a group of people who live together and share income and expenses (even if they are not
related to each other).
Examples of one household:
• A married couple who live together are one household. They must share one Lifeline benefit.
• A parent/guardian and child who live together are one household. They must share one Lifeline benefit.
• An adult who lives with friends or family who financially support him/her are one household. They must
share one Lifeline benefit.
Examples of more than one household:
• 4 roommates who live together but do not share money are 4 households. They can have one Lifeline
benefit each, 4 total.
• 30 seniors who live in an assisted-living home are 30 households. They can have one Lifeline benefit each,
A household shares expenses. Household expenses include, but are not limited to, food, healthcare
expenses, and the cost of renting or paying a mortgage on your place of residence and utilities.
Households share income. Income includes salary, public assistance benefits, social security payments,
pensions, unemployment compensation, veteran’s benefits, inheritances, alimony, child support payments,
worker’s compensation benefits, gis, and lottery winnings.
Lifeline is a benefit that lowers the monthly cost of phone or internet service.
You are only allowed to get one Oregon Lifeline benefit per household, not per person.
Your Information - Please print clearly.
All highlighted fields are required.
Full legal name
Home address (The address where you will get service. Do not use a P.O. Box)
City Zip CodeState
Apt., Unit, etc.
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