Lifeline Benefit Program

By completing this form, you acknowledge and give your affirmative consent that you want to participate in the Lifeline Program through Triangle Communications and that I understand and certify that:

• Lifeline Program support is a federal benefit that provides a monthly discount on home phone (i.e., landline phone) or cell phone service.
• I understand that my household can only receive one Lifeline service, and to the best of my knowledge, my household is not already receiving a Lifeline service.
• I understand that 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.
• I understand that a household is not permitted to receive Lifeline benefits from multiple providers.
• I understand that violation of the one-per-household limitation constitutes a violation of the Federal Communications Commission’s (FCC) rules and will result in my de-enrollment from the program.
• I understand that Lifeline is a non-transferable benefit and that I may not transfer it to any other person
• I certify that I meet the income-based or program-based eligibility criteria for receiving Lifeline, provided in 47 CFR § 54.409 and that I have provided any required documentation of eligibility.
• I certify that the individual named on the documentation provided, demonstrating program-based eligibility, if not me, is part of my household.
• I certify that I will notify Triangle Communications within 30 days if for any reason I no longer satisfy the criteria for receiving Lifeline including, as relevant, if I no longer meet the income-based or program-based criteria for receiving Lifeline support, I’m receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline benefit.
• (Only if applicable) I understand that to qualify for the Tribal Lifeline Benefit my place of residence must be on Tribal Land and I certify that my current residence is on Tribal lands, as defined in 47 CFR Section 54.400(e).
• If I move to a new address, I will provide that new address to Triangle Communications within 30 days.
• I acknowledge that I may be required to re-certify my continued eligibility for Lifeline at any time, and my failure to re-certify as to my continued eligibility will result in de-enrollment and the termination of my Lifeline benefits pursuant to 47 CFR § 54.405(e)(4).
• I understand that information formm this application will be given to USAC and/or its agents for purpose of verifying that my household does not receive more than one benefit and that USAC may require additional information in order to verify my eligibility.
• I affirm that all the answers and agreements that I provided on this form are true and correct to the best of my knowledge.
• I acknowledge that Lifeline is a federal benefit and I know that willingly giving false or fraudulent information to get Lifeline benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program.

Additional disclosure for transfers: I give my affirmative consent to transfer my Lifeline benefit to Triangle Communications and agree and certify that:

• I understand that, once the transfer is complete, I will lose my Lifeline program benefit with my former Lifeline service provider.
• I acknowledge that my new Lifeline service provider has explained that I cannot have multiple Lifeline program benefits with the same or different service providers.

Finally, by completing this for you are consenting to provide lifeline subscriber information to the national lifeline accountability database.

The Federal Communications Commission has established the National Lifeline Accountability Database (NLAD) to detect and prevent consumers from receiving more than one discounted telephone service under the federal Lifeline program. Under federal law, Triangle Communications is required to check this database prior to signing up Lifeline subscribers and is also required to provide the following information regarding each new and existing Lifeline subscriber to the federal database’s administrator:

• The Lifeline subscriber’s full name;
• The Lifeline subscriber’s full residential Address;
• The Lifeline subscriber’s date of birth;
• The last four digits of the Lifeline subscriber’s Social Security number or Tribal Identification Number (if the subscriber is a Tribal member and does not have a Social Security number);
• The telephone number associated with the Lifeline service;
• The date on which the Lifeline service was initiated;
• The date on which the Lifeline service was terminated (if applicable);
• The amount of Lifeline service support being sought for the subscriber;
• The means through which the subscriber qualified for Lifeline service (income or program-based, Medicaid, SNAP, etc.).

The above information related to your Lifeline service is being provided by Triangle Communications to the National Lifeline Accountability Database to verify that you, as a Lifeline applicant and/or subscriber, are not receiving more than one Lifeline benefit, and to otherwise ensure proper administration of the Lifeline program. If the National Lifeline Accountability Database indicates you already receive a Lifeline benefit, Triangle Communications will be required to deny the benefit to your account.

Authorization:

I, the Lifeline applicant/subscriber, acknowledge that Triangle Communications will transmit to the administrator of the National Lifeline Accountability Database the above-referenced information about my Lifeline account and/or service for inclusion into the Database, and hereby consent to transmission of the information for purposes allowed by law relating to administration of the Lifeline program.

I further understand that a failure to provide this consent to release my Lifeline account and/or service information to the federal administrator for inclusion in the National Lifeline Accountability Database will result in a denial of or de-enrollment from Lifeline service.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.