Please completely READ, INITIAL each rule, and SIGN this form indicating that you
understand and agree to comply with the following Oregon Lifeline rules:
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 understand it may take 30-90 days for the company to apply the Oregon Lifeline benefit to my
account.
I give the Oregon Public Utility Commission (PUC), the Federal Communication Commission,
and the Universal Service Administrative Company authority to obtain or review any required
records needed to confirm my statements and to confirm that I qualify for the Oregon Lifeline
benefit. I also authorize the company to release any required records for my Oregon Lifeline
benefit.
I am head of household and no one else in my household receives landline, wireless or Broadband
Lifeline service.
I understand that the Oregon Lifeline credit is allowed for ONE ACCOUNT PER HOUSEHOLD
• Ahouseholdisdefinedasanypersonswholivetogetheratthesameaddressandshareincome
and expenses.
I understand that if I break or violate the one-per-household rule I will no longer qualify for the
Oregon Lifeline benefit.
I agree to let the PUC know within 30 days if:
IunderstandthatIhave30daystonotifythePUCifInolongerqualifyfortheOregonLifelinebenetorI
may be removed from the program.
I agree to notify the PUC of address changes within 30 days of moving.
I understand that my Oregon Lifeline benefit may not be transferred or given to any other person.
IunderstandthatImayberequiredtoconrmthatIstillqualifyfortheOregonLifelinebenetatanytime
andthat,ifIdonotcomply,myOregonLifelinebenetswillstop.
I understand that Oregon Lifeline is a state and federal benefit and willfully making false statements
or providing false or fraudulent documents to obtain the benefit is punishable by law and can result
in fines, imprisonment, disqualification or being permanently removed from the program.
PAGE 3
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Make sure your application is complete before sending it. Did you:
Complete Sections 1, 2a or 2b, and Section 3 of the application?
Include current documentation from Sections 2a or 2b (if needed)?
Failure to provide current documentation may result in denial or delay of your application.
Please mail completed application (with current documentation, if needed) to:
PUC•POBox1088•Salem,OR97308ORFaxto1-877-567-1977or503-378-6047
By signing this application I certify under penalty of perjury that the information contained in this
application is true and correct and that I meet the eligibility criteria for the Oregon Lifeline benefit.
Applicant Signature:
Print Name: Date:
• Inol
onger qualify for the Oregon Lifeline benefit
• IreceivemorethanoneOregonLifelinebenefit
• Idisco
nnected service with my company
• AnothermemberofmyhouseholdisalsoreceivingtheOregonLifelinebenefit
Applicant MUST initial each box below:
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Initial
FM784ENG (5/6/2020)
