FCC FORM **** OMB APPROVAL EDITION ****-****

Lifeline Program

Application Form

Page 1 of 8

Need help? Call the Lifeline Support Center at 1-800-***-**** Universal Service Administrative Company www.lifelinesupport.org 1.

About

Lifeline

Lifeline is a federal

benefit that lowers the

monthly cost of phone

or internet service.

Rules

If you qualify, your household can get Lifeline for phone or internet service, but not both.

• If you get Lifeline for phone service, you can get the benefit for one mobile phone or one home phone, but not both.

• If you get Lifeline for internet service, you can get the benefit for your mobile phone or your home connection, but not both.

• If you get Lifeline for bundled phone and internet service, you can get the benefit for your mobile phone bundled service or your home bundled service, but not both. Your household cannot get Lifeline from more than one phone or internet company. You are only allowed to get one Lifeline benefit per household, not per person. If more than one person in your household gets Lifeline, you are breaking the FCC’s rules and will lose your benefit. What is a household?

A household is a group of people who live together and share income and expenses (even if they are not related to each other).

Do not give your benefit to another person

Lifeline is non-transferable. You cannot give your Lifeline benefit to another person, even if they qualify. Be honest on this form

You must give accurate and true information on this form and on all Lifeline-related forms or questionnaires. If you give false or fraudulent information, you will lose your Lifeline benefit (i.e., de-enrollment or being barred from the program) and the United States government can take legal actions against you. This may include (but is not limited to) fines or imprisonment.

You may need to show other documents

You will need to show your phone or internet company an official document from one of the government qualifying programs or prove your annual income. Please provide copies of your official documents with this application. Include the documents in option 1 or option 2 below: 1. If you qualify through a government program: copies of your state ID card and an official document from the program you are qualifying through (your SNAP card, Medicaid card, Supplemental Security Income (SSI) benefit letter, Federal Public Housing Assistance (FPHA) award letter, or other accepted documents).

2. If you qualify through your income: copies of your state ID card and your last state, federal, or Tribal tax return, pay stubs for 3 consecutive months, or other accepted documents. Visit lifelinesupport.org to see the full list of accepted documents. Visit lifelinesupport.org to see the full list of accepted documents. Apply

To apply for a Lifeline benefit, fill out the required sections of this form, initial every agreement

statement, and sign on page 6.

To apply, bring or mail this form to your phone or internet company.

P.O. Box 220009

Milwaukee, OR 97269-0009

FCC FORM 5629 OMB APPROVAL EDITION 3060-0819

Lifeline Program

Application Form

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Need help? Call the Lifeline Support Center at 1-800-***-**** Universal Service Administrative Company www.lifelinesupport.org What is your full legal name?

The name you use on official documents, like your Social Security Card or State ID. Not a nickname. What is your phone number (if you have one)?

First

2.

Your

Information

All fields are required

unless indicated. Use only

CAPITALIZED LETTERS

and black ink to fill out

this form. What is your date of birth?

Month Day Year

What is your email address (if you have one)?

What are the last 4 numbers of your Social Security Number (SSN)? If you do not have a SSN, what is your Tribal Identification Number? Middle (optional) Suffix (optional)

Last

What is the best way to reach you?

email phone text message mail

17

TERRY

246*****-**

135029246

adckuk@r.postjobfree.com

817

3344

FULCHER

543

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Lifeline Program

Application Form

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Need help? Call the Lifeline Support Center at 1-800-***-**** Universal Service Administrative Company www.lifelinesupport.org 2.

Your

Information

(continued)

* Tribal lands include any federally recognized

Indian tribe’s reservation, pueblo, or colony,

including former reservations in Oklahoma;

Alaska Native regions established pursuant to

the Alaska Native Claims Settlement Act (85

Stat. 688); Indian allotments; Hawaiian Home

Lands—areas held in trust for Native Hawaiians

by the state of Hawaii, pursuant to the Hawaiian

Homes Commission Act, 1920 July 9, 1921,

42 Stat. 108, et. seq., as amended; and any

land designated as such by the Commission

for purposes of this subpart pursuant to the

designation process in the FCC’s Lifeline rules.

What is your home address? (The address where you will get service. Do not use a P.O. Box) Street Number and Name

City

State Zip Code

Apt., Unit, etc.

Is this a temporary address? Yes No Check if you live on Tribal Lands* What is your mailing address? (Only fill this out if it is not the same as your home address.) Street Number and Name

City

State Zip Code

Apt., Unit, etc.

TN 38116

4403 BOEINGSHIRE DR

MEMPHIS

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Lifeline Program

Application Form

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Need help? Call the Lifeline Support Center at 1-800-***-**** Universal Service Administrative Company www.lifelinesupport.org 2.

Your

Information

(continued)

Check if you are qualifying through a child or dependent in your household. If so, answer the following questions:

What is their full legal name?

Only fill this section

out if you are applying

through a child or

dependent.

First

What is their date of birth?

Month Day Year

What are the last 4 numbers of their Social Security Number (SSN)? If they do not have a SSN, what is their Tribal Identification Number? Middle (optional) Suffix (optional)

Last

FCC FORM 5629 OMB APPROVAL EDITION 3060-0819

Lifeline Program

Application Form

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Need help? Call the Lifeline Support Center at 1-800-***-**** Universal Service Administrative Company www.lifelinesupport.org Check all programs that you or someone in your household have: Supplemental Nutrition Assistance Program (SNAP) (Food Stamps) Supplemental Security Income (SSI)

Medicaid

Federal Public Housing Assistance (FPHA)

Veterans Pension or Survivors Benefit Programs

Tribal Specific Programs

Bureau of Indian Affairs (BIA) General Assistance

Tribal Temporary Assistance for Needy Families (Tribal TANF) Food Distribution Program on Indian Reservations (FDPIR) Tribal Head Start (only households that meet the income qualifying standard) Qualify through a government program:

Or

Qualify through your income:

(Only fill this out if you do not qualify through a government program.) 3.

Qualify for

Lifeline

Fill out this section to

show that you, your

dependent, or someone

in your household

qualifies for Lifeline.

You can qualify through

some government

assistance programs or

through your income (you

do not need to qualify

through both).

Including you, how

many people live in your

household? (check one)

Is your income the same or less than the amount listed for your state and household size?

(only check yes or no next to your household size) All 48 States & DC

(not Alaska and Hawaii)

Alaska Hawaii

1 $16,389 $20,493 $18,846 Yes No

2 $22,221 $27,783 $25,555.50 Yes No

3 $28,053 $35,073 $32,265 Yes No

4 $33,885 $42,363 $38,974.50 Yes No

5 $39,717 $49,653 $45,684 Yes No

6 $45,549 $56,943 $52,393.50 Yes No

7 $51,381 $64,233 $59,103 Yes No

8 $57,213 $71,523 $65,812.50 Yes No

If more than 8, add this

amount for each extra person:

Add $5,832 Add $7,290

Add

$6,709.50 Yes No

135% of the 2018 Federal Poverty Guidelines

*The Federal Poverty Guidelines are typically updated at the end of January.

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Lifeline Program

Application Form

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Need help? Call the Lifeline Support Center at 1-800-***-**** Universal Service Administrative Company www.lifelinesupport.org Signature Today’s Date

4.

Agreement

I agree, under

penalty of perjury,

to the following

statements:

You must initial next to

each statement.

Initial

I (or my dependent or other person in my household) currently get benefits from the government program(s) listed on this form or my annual household income is 135% or less than the Federal Poverty Guidelines (the amount listed in the Federal Poverty Guidelines table on this form). Initial

I agree that if I move I will give my service provider my new address within 30 days. Initial

I understand that I have to tell my service provider within 30 days if I do not qualify for Lifeline anymore, including:

1) I, or the person in my household that qualifies, do not qualify through a government program or income anymore.

2) Either I or someone in my household gets more than one Lifeline benefit (including, more than one Lifeline broadband internet service, more than one Lifeline telephone service, or both Lifeline telephone and Lifeline broadband internet services). Initial

I know that my household can only get one Lifeline benefit and, to the best of my knowledge, my household is not getting more than one Lifeline benefit. Initial

I agree that my service provider can give the Lifeline Program administrator all of the information I am giving on this form. I understand that this information is meant to help run the Lifeline Program and that if I do not let them give it to the Administrator, I will not be able to get Lifeline benefits. Initial

All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.

Initial

I know that willingly giving false or fraudulent information to get Lifeline Program benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program.

Initial

My service provider may have to check whether I still qualify at any time. If I need to recertify

(renew) my Lifeline benefit, I understand that I have to respond by the deadline or I will be removed from the Lifeline Program and my Lifeline benefit will stop. Initial

I was truthful about whether or not I am a resident of Tribal lands, as defined in section 2 of this form.

I consent to let USAC contact me at my Lifeline

phone number for important reminders and

updates to my Lifeline service. Message and data

rates may apply. Text STOP to end messages.

TF

Electronically Signed by TERRY FULCHER December 21, 2018 TF

TF

TF

TF

TF

TF

TF

TF

12/21/2018

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Lifeline Program

Application Form

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Need help? Call the Lifeline Support Center at 1-800-***-**** Universal Service Administrative Company www.lifelinesupport.org 5.

Agent

Information

Answer only if a sales

person submits this form.

What is the agent’s full legal name?

The name you use on official documents, like your Social Security Card or State ID. Not a nickname. What is the agent’s ID number?

First

What is the agent’s date of birth?

Month Day Year

Middle (optional) Suffix (optional)

Last

FCC FORM 5629 OMB APPROVAL EDITION 3060-0819

Lifeline Program

Application Form

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Need help? Call the Lifeline Support Center at 1-800-***-**** Universal Service Administrative Company www.lifelinesupport.org Notice

PAPERWORK REDUCTION ACT NOTICE: Section 54.410 of the Federal Communications Commission’s rules requires all Lifeline subscribers to demonstrate their eligibility to receive Lifeline services. This collection of information stems from the Commission’s authority under Section 254 of the Communications Act of 1934, as amended, 47 U.S.C. §254. Using this authority, the FCC has designated USAC as the permanent Lifeline Administrator. The FCC has published rules detailing how consumers can qualify for Lifeline services and what Lifeline services they may receive (47 CFR §54.400 et seq.). The data provided in response to this information collection will be used by USAC to verify the applicant’s eligibility for Lifeline services. We have estimated that each response to this collection of information will take, on average, between 0.25 and 0.75 hours. Our estimate includes the time to read the questions, look through existing records, gather the required data, and actually complete and review the form or response. If you have any comments on this estimate, or how we can improve the collection and reduce the burden it causes you, please write to the Federal Communications Commission, OMD-PERM, Paperwork Reduction Project

(3060-0819), Washington, D.C. 20554. We also will accept your comments via the Internet if you send them to adckuk@r.postjobfree.com. Please DO NOT SEND COMPLETED DATA COLLECTION FORMS TO THIS ADDRESS. Remember – You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid Office of Management and Budget

(OMB) control number. This collection has been assigned an OMB control number of 3060-0819. The Commission is authorized under the Communications Act of 1934, as amended, to collect the information we request on this form. If we believe there may be a violation or potential violation of a statute or a Commission regulation, rule, or order, your response may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order. If you do not provide the information we request on this form, you will not be eligible to receive Lifeline services under the Lifeline Program rules, 47 C.F.R. §§ 54.400-54.423.

The foregoing Notice is required by the Paperwork Reduction Act of 1995, P.L. No. 104-13, 44 U.S.C. § 3501, et seq. PRIVACY ACT STATEMENT: The Privacy Act is a law that requires the Federal Communications Commission (FCC) and the Universal Service Administrative Company (USAC) to explain why we are asking individuals for personal information and what we are going to do with this information after we collect it. Authority: Section 254 of the Communications Act (47 U.S.C. § 254), as amended, 47 U.S.C. §254, authorizes the FCC to operate the Lifeline program. Using this authority, the FCC has designated USAC as the permanent Lifeline Administrator. The FCC has published rules detailing how consumers can qualify for Lifeline services and what Lifeline services they may receive (47 CFR

§54.400 et seq.).

Purpose: We are collecting this personal information so we can verify that you qualify for the Lifeline program and so we can efficiently provide Lifeline services to you. We access, maintain and use your personal information in the manner described in the Lifeline System of Records Notice (SORN), FCC/WCB-1, which we have published in 82 Fed. Reg. 38686 (Aug. 15, 2017). Routine Uses: We may share the personal information you enter into this form with other parties for specific purposes, such as: with contractors that help us operate the Lifeline program; with other federal and state government agencies that help us determine your Lifeline eligibility; with the telecommunications companies that provide you Lifeline service; and with law enforcement and other officials investigating potential violations of Lifeline rules. A complete listing of the ways we may use your information is published in the Lifeline SORN described in the “Purpose” paragraph of this statement.

Disclosure: You are not required to provide the information we are requesting, but if you do not, you will not be eligible to receive Lifeline services under the Lifeline Program rules, 47 C.F.R. §§ 54.400-54.423. Your Plan Features

LIFELINE ASSISTANCE PROGRAM . TENNESSEE CERTIFICATION FORM PromoCode: WASL512 Enrollment ID: 39097770

Section 1

Section 2

You MUST initial all statements. (Your application cannot be approved without these items.) TF

I authorize SafeLink Wireless® or its duly appointed representative to: (1) access any records required to verify my statements herein (2) to confirm my continued eligibility for Lifeline assistance; (3) to update my address to proper mailing address format; (4) to provide my name, telephone number, and address to the Universal Service Administrative Company (USAC) (the administrator of the program) and/or its agents for the purpose of verifying that I do not receive more than one Lifeline benefit; and (5) authorize social service agency representatives to discuss with and/or provide information to SafeLink Wireless® verifying my participation in benefit programs that qualify me for Lifeline assistance. This service is supported by LifeLine. Lifeline is a federal benefit that makes monthly telephone and broadband service more affordable for eligible households. Your household may receive the Lifeline benefit for telephone service OR broadband service, but not both. For Lifeline telephone service, your household may receive the Lifeline benefit for one mobile OR one fixed home telephone service, but not both. For Lifeline broadband service, your household may receive the Lifeline benefit for one mobile broadband OR one fixed broadband service, but not both. Your household may not receive the Lifeline benefit from more than one service provider. For the purpose of Lifeline, a household is an individual or any group of individuals who live together at the same address and share income and expenses. Lifeline is a non-transferable benefit. You may not transfer your Lifeline benefit to another person, even if he or she is eligible. You will lose your Lifeline benefit and may be prosecuted by the United States government if you violate the one-per-household rule or otherwise make false statements to receive the Lifeline benefit.

*Unused balance will not carryover from month to month. Keep Your Own Smartphone

1,000 FREE monthly minutes & unlimited

texts. Receive 1.5GB/month of FREE data

for the first 3 months of service and

1GB/month thereafter.

You must have a compatible

phone or other Unlocked GSM

phone in order to participate in

the SafeLink Keep Your Own

Smartphone plan.

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