Lifeline Program Consent Form

Contact Information- Please enter the information exactly as submitted to the National Verifier. Any differences (such as nicknames, titles, misspellings, etc.) may cause your application to be rejected.

National Verifier Application ID (starts with a Q): *

First Name: *

Last Name:

Date of Birth: *

Last four digits of Social Security Number #: *

Street Address: *

CIty: *

State: * - Select a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code: *

Email Address: *

Phone Number: *

Benefit Qualifying Person- If the benefit-qualifying person is not the person listed above, complete the below certification. (Examples include: child of an above-named individual, the above-named individual is named power of attorney for qualifying participant; qualifying participant is disabled but resides in the same household as the above-named individual.)

Did you qualify for the program because of a dependent? *

• Yes
• No

Dependent Information- Only fill out the information below if you selected yes to the question above.

First Name:

Last Name:

Dependent Date of Birth:

Last four digits of Dependent's Social Security Number:

Disclosures

Willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the Lifeline program.

Only one Lifeline benefit is available per household. A household is not permitted to receive discounted Lifeline services from multiple providers. A household is defined, for purposes of the Lifeline program, as any individual or group of individuals who live together at the same address and share income and expenses. Violation of the one-per-household limitation constitutes a violation of the FCC’s rules and will result in you being de-enrolled from the Lifeline program.

Lifeline discount benefits are not transferrable to other households or persons. Eligibility for Lifeline is determined by the National Verifier and National Lifeline Accountability Database, administered by the Universal Service Administrative Company (USAC).

Acknowledgments

(1)  I will notify MEC within 30 days if for any reason I no longer satisfy the criteria for receiving Lifeline, I am receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline benefit

(2)  If I move to a new address, I will provide that new address to MEC within 30 days

(3)  My household will receive only one Lifeline service, and to the best of my knowledge, my household is not already receiving a Lifeline service

(4)  The information contained in this certification form is true and correct to the best of my knowledge

(5)  I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law

(6)  I acknowledge that I may be required to re-certify my continued eligibility for Lifeline at any time, and my failure to re-certify my continued eligibility will result in de-enrollment and the termination of my Lifeline benefits pursuant to FCC rule 47 C.F.R. §54.405(e)(4).

Click here to indicate that you have read the disclosures and agree to the acknowledgements above, agree to the terms of the Lifeline Program and you authorize MEC to share your information with USAC, for the purpose of establishing eligibility for and enrolling in the Lifeline program. Information shared includes, but is not limited to, full name, full residential address, date of birth, last four digits of social security number, telephone number, eligibility criteria and status. The information you are providing may be considered sensitive personal information. While privacy laws give you the right to limit how we use or disclose such data, we are required by other laws to keep and store the information for certain periods of time.

• I agree

Failure to provide consent will result in me being denied Lifeline benefits.