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Obamaphone App

This document is an application for the Wisconsin Lifeline Assistance Program. It requests personal information such as name, address, and phone number. It asks the applicant to choose a phone plan and provides details on plan options. It also asks the applicant to verify their eligibility by certifying participation in a public assistance program or verifying their household income is at or below specified levels. The applicant must sign to affirm the accuracy of the information provided and authorize the carrier to access records to verify their eligibility for the Lifeline program.

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Vicki McKenna
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© Attribution Non-Commercial (BY-NC)
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764 views

Obamaphone App

This document is an application for the Wisconsin Lifeline Assistance Program. It requests personal information such as name, address, and phone number. It asks the applicant to choose a phone plan and provides details on plan options. It also asks the applicant to verify their eligibility by certifying participation in a public assistance program or verifying their household income is at or below specified levels. The applicant must sign to affirm the accuracy of the information provided and authorize the carrier to access records to verify their eligibility for the Lifeline program.

Uploaded by

Vicki McKenna
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FULL CERTIFICATION APPLICATION FOR WISCONSIN LIFELINE ASSISTANCE PROGRAM

Pr"lvirl", only correct personal information. It will be validated against Public Records, any discrepancies will result in Rejection of service.
Select if address is temporary: 0
D
Plan Features
Choose your plan (check one)
Local Calls
National Long Distance
Voice Mail
Nationwide Text (0.3 minutes per text) ... (1 minute per text)
Roaming at no Additional Cost
Free911
411 Directory Assistance at no Additional Cost
Carry-Over Minutes from Month to Month
100+ International Long Distance Destlnatlons*
x
"* List of destinations available at vvww,SafeLink.com
** If you choose this plan, your unused minutes will be removed/wiped out and will not carry-over on your next monthly minutes delivery. However, if you purchase and redeem additional minutes
cards, all unused minutes will carry over for three consecutive months,
x
X
Select ONE of the two options below (Proof of eligibility MUST be submitted for either option, name and address must match applicant).
Qualify by certifying you belong to ONE of the programs listed below, Qualify by checking the number of people in your family and your monthly
D
programs with (*) DO NOT require proof. Remaining programs require income, attach proof of income such as last year's Federal or State Income Tax
an award letter from SSA or state agency stating that you receive the
return, a Social Security statement of benefit, a letter from your employer, pay
benefit, or a Similar official document. Provide Copies ONLY
stubs from 3 consecutive months, an Unemployment or Workmen's Compen
sation statement of benefits, a Retirement/Pension statement of benefits or
adivorce decree, child support award, or other official document containing
o Badger Care*
income information. Provide Copies ONLY
oSupplemental Nutrition Assistance Program (SNAP) FoodStamps*
o Low Income Home Energy Assistance (UHEAP)*
o Medical Assistance (Medicaid)*
o Supplemental Security Income (SSI)*
o WisconsinWorks (W-2)*
o Temporary Assistance for Needy Families (TANF)*
o WI Homestead Tax Credit (Schedule H)
o Federal Public Housing Assistance (Section 8)
o National School Lunch Program's free lunch program
* Programs are validated by a state agency (No Proof required)
Persons in Family or Household
1
0
2
0
3 0
4
0
5 0
6
0
7 0
8
0
For each additional person, add:
Annual Income Monthly Income
$15,080 $1,257 0
$20,426 $1,702 0
$25,772 $2,148 0
$31,118 $2,593 0
$36,464 $3,039 0
$41,810 $3,484 0
$47,156 $3,930 0
$52,502 $4,375 0
$5,346 $446 0
SafeLink" is a Lifeline supported service. Lifeline is a federal benefit, and only eligible subscribers may enroll. Customers who willfully make false statements in order to obtain
the benefit can be punished byfine or imprisonment or ccln be barred from the program.
Ufeline is available for only one line per household. A household is defined as any individual or group of individuals who live together at the same address and share income
and expenses. A household is not permitted to receive Lifeline benefits from multiple providers. Violation ofthe one-per-household rule constitutes a violation of FCC rules,
and will result in the Customer's disenrollmentfrom Lifeline. Ufeline is a non-transferable benefit, and a Customer may not transfer his or her benefrt to another person.
o Check this box if you would like to receive pre-recorded special offers and promotional offers from TracFone at the Contact Telephone number provided above.
o REFERRED BY A FRIEND:
Customer's First Name Customer's Last Name SafeLink Phone Number
.. You MUSTcheckoff ( ., ) all statements, then Sign and Date application. (Your application cannot beapproved without these items)
I certify under penalty of perjury to each of the following:
.. 0 I participate in the above designated qualifying program OR have income at or below the level specified above.
j 0 ! understand that I must notify safetink within 30 days if I no longer participate in the qualifying program or meet
the income eligibility threshold, if I r, another member of my household obtains Lifeline supported service from
.s:: another carrier, Of, for any other I no longer qualify for Lifeline support. .
.. 0 I understand I may be required to rE1certify my continued eligibility for Lifeline at any time, and failure to do so will
- result in termination of my Lifeline E;nefits.
t;; .. 0 If I change my address, I will provid my new address to SafeLink within 30 days.
;:)
.. 0 My household will receive only one Lifeline benefit and to the best of my knowledge, my household is not already
:G receiving a Lifeline service.
.. 0 The information contained in this al1>plication is true and accurate to the best of my' knowledge, and I acknowledge
t:IIl that providing false or fraudulent information to obtain lifeline benefits is punishable by law;
Iauthorize SafelinkWireless or its duly appointed representative toI'1)... access any records required to verify my statements herein; (2) to confirm my continUed. eligibililyfor Lifeline assistance; (3)
to update myaddress to a proper mailing address format; (4) to pro ide my name, telephone number, and address to the Universal Service Administrative Company (USAC) (the administrator
ofthe program) and/or its agents for the purpose ofveri/ying that I a not receive more than one Ufuline benefit; and (5) authorize sodaIservice agency representatives to discuss with and!
or provide information to SafelinkWireless verifying my participati . in benefit programs that qualify me for Lifeline assistance (6) to access records relating to me and my family that are in the
CARES Medicaid database maintained by the Wisconsin Departmefjt of Health Services and 1;he Wisconsin Department ofChildren and Families. TIle only authorized purpose for this access is to
verify my eligibility for the Lifeline program. SafeLinkWireless'" is not authorized to usethese records for any other purpose orto disclose them to anyone else.This release is not valid unless adate is
written after my signature.The release expires two years after that te.lfthe WI HomesteadTax Credit (Schedule H) is selected Iauthorize, the Department of. Revenue to provide verification of my
eligibilityas aHomestead Credit recipient to SafelinkWlreless, orth iragents as necessary, while Iam aparticipant in the Lifeline program. .
By signing below, I separately affirm and ag ee to each of the above statements .
Applicant Signature I Date ___..,.--_____
For questions please call1-800-SafeLink (1-800-723-3$46) Fax application to: 1-866-902-S7S6 Promo Code: FAST10
Mail application to: SafeLink Wireless PO Box 2200,9 Milwaukie, OR 97269-0009 To get phone faster apply at www.safelink.com

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