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,
30 total.
Household expenses
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.
Income
Households share income. Income includes salary, public assistance benefits, social security payments,
pensions, unemployment compensation, veteran’s benefits, inheritances, alimony, child support payments,
workers compensation benefits, gis, and lottery winnings.
Oregon Lifeline
Household Worksheet
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.
1
Your Information - Please print clearly.
All highlighted fields are required.
Full legal name
First
Middle
Last
Home address (The address where you will get service. Do not use a P.O. Box)
City Zip CodeState
Oregon
Apt., Unit, etc.
PLEASE CONTINUE TO PAGE 2
PAGE 1
FM951ENG (9/10/18)
PAGE 2
You do not qualify for Lifeline because someone
in your household already gets the benefit. You
are only allowed to get one Lifeline discount per
household, not per person.
You can apply for
Lifeline. You live in a
household that does
not get Lifeline yet.
Please initial line
B
below, and sign and
date the worksheet.
You can apply for Lifeline.
You live at an address with
more than one household
and your household does
not get Lifeline yet.
Please initial lines
A
and
B
below, and sign and date
the worksheet.
2. Do they get Lifeline?
Yes No
1. Do you live with another adult?
Adults are people who are 18 years old or older, or who are emancipated minors. This can include a
spouse, domestic partner, parent, adult son or daughter, adult in your family, adult roommate, etc.
Yes No
3. Do you share money (income and expenses) with them?
This can be the cost of bills, food, etc., and income. If you are married,
you should check yes for this question.
Yes No
If yes, answer
question 3
If yes, answer
question 2
Can you apply?
Follow this decision tree to confirm if you qualify for the Oregon Lifeline Program.
2
Agreement
Please initial the agreement below and sign and date this worksheet.
A
I live at an address with more than one household.
B
I understand that the one-per-household limit is a Federal Communications Commission (FCC)
rule and I will lose my Lifeline benefit if I break this rule.
3
Initial
Initial
Applicant Signature: Date:
/ /
Month Day Year
FM951ENG (9/10/18)
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