Lifeline Transfer-In 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.

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

I acknowledge that my Lifeline Program benefit will be transferred to MEC.

I understand that my Lifeline Program benefit will be applied to service from MEC and will no longer be applied to service retained by my previous provider.  I understand I may be subject to my previous service provider’s regular rates if I retain services from them.

I understand that I cannot have multiple Lifeline Program benefits with the same or different service providers.

Click here to indicate that I have read the disclosures related to my request to transfer my Lifeline Program benefit. I understand these disclosures and I consent to the transfer of my Lifeline benefit to MEC.

• I consent