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ReachOut Web Form

LifeLine-LinkUp Self Certification Form-Program Based eligibility Enrollment Number: I hereby certify that I participate in a minimum of one of the following programs: food stamps. I authorize representatives of the above programs to discuss with and / or provide copies if requested by the company. I hereby authorize Nexus Communications, Inc., d / b / a reachout wireless, to access records relating to me and my family, that are in any state or federal database

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60 views

ReachOut Web Form

LifeLine-LinkUp Self Certification Form-Program Based eligibility Enrollment Number: I hereby certify that I participate in a minimum of one of the following programs: food stamps. I authorize representatives of the above programs to discuss with and / or provide copies if requested by the company. I hereby authorize Nexus Communications, Inc., d / b / a reachout wireless, to access records relating to me and my family, that are in any state or federal database

Uploaded by

Cara Bear
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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LifeLine-LinkUp Self Certification Form-Program Based Eligibility Enrollment Number :

I hereby certify that I participate in a minimum of one of the following programs:

Food Stamps Federal Public Housing Assistance-Section 8 National School Lunch Free Lunch Program Bureau of Indian Affairs Programs

Supplemental Social Security-SSI Temporary Assistance to Needy Families-TANF Low Income Home Energy Assistance Program-LIHEAP Medicaid

FIRST NAME Service Address Address ----------------------------------------------------------------------------------------------Apt. or ----------------------------------------------------------------------------------------------Unit City ----------------------------------------------------------------------------------------------State ----------------------------------------------------------------------------------------------Zip ----------------------------------------------------------------------------------------------Code

LAST NAME

--------------------------SOCIAL SECURITY NUMBER


Choose The Plan That Suits Your Lifestyle

DATE OF BIRTH *250 FREE Minutes

125 FREE Minutes

*250 Free Minute Plan minutes DO NOT roll over to the next month. All unused minutes expire and your phone is loaded with a new balance of 250 minutes each month.
I hereby authorize Nexus Communications, Inc., d/b/a ReachOut Wireless" or its duly appointed representative to access records relating to me and my family, that are in any state or federal database to verify my eligibility for the Lifeline/Linkup program. I authorize representatives of the above programs to discuss with and/or provide copies if requested by the company, to verify my participation in the above selected programs and my eligibility for Lifeline or Link-Up service and that I will notify my telecommunications provider if and when I am no longer participating in at least one of the above-designated programs. I certify that I have not utilized Link-Up at my existing address. I certify that I do not currently have Lifeline service and no other resident at my residential address participates in the Lifeline program. If I have Lifeline service now I agree to cancel my current Lifeline support in favor of ReachOut Wireless". I affirm that I am head of household and that I am not claimed as a dependant on another person\'s federal or state income tax return. I agree to notify ReachOut Wireless" if I have a change of address. I affirm, under penalty of perjury, that the foregoing representations are true and correct to the best of my knowledge and belief.

APPLICANT'S SIGNATURE:

--------------------------------------------------------------------- DATE:----------------

Certification is good for up to one year from the date of signing. This certification must be updated annually to avoid program termination. Submit your application 3 ways!

Email Email To: [email protected]

Fax Toll Free : 1-877-870-9333


Customer Service:1-877-870-9444

Mail PO BOX 247168 Columbus, Ohio 43224


www.reachoutwireless.com

Orders are shipped immediately upon receipt of signed form. Please allow 3 to 5 business days for shipping. Cellular phone models vary upon availability. All enrollment forms must have all sections completed. This includes: full social security number, date of birth, and it must be signed and dated. Only one phone per household address allowed regardless of how many government assisted recipients reside at the address. We can only ship to a home address and NOT a PO Box. There are absolutely no exceptions.

Nexus Communications Inc. d/b/a Reachout Wireless PO Box 247168 Columbus, Ohio 43224-7168 Certain restrictions apply. Phone models vary by availability. Service varies by coverage area. Not available in all areas. Copyright 2009. All Rights Reserved.

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