Florida Public Service Commission








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English Lifeline Form
Official Seal for the State of Florida

Lifeline Florida On-line Application for Recipients of Medicaid or Supplemental Nutrition Assistance Program (SNAP)

ABOUT SSL CERTIFICATES
Section 364.107(1), Florida Statutes provides that personal identifying information concerning a participant in a telecommunications carrier's Lifeline Assistance Plan held by the Public Service Commission is confidential.
Lifeline is a federal benefit. Willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the program. Only one Lifeline service is available per household. 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. For example, apartments in an apartment building are usually unique households. Individuals living in a nursing home can be considered unique households. Answer the questions below to determine if there is more than one household living at your address.
Does another adult (age 18 or older or emancipated minor) live with you AND have a Lifeline-discounted service or a “free” wireless Lifeline service? For example, husband, wife, domestic partner, parent, son, daughter, another relative (such as a sibling, aunt, cousin, grandparent, grandchild, etc.), a roommate, or another person. Yes No
Do you share expenses for bills, food, or other living expenses AND share income (salary, public assistance benefits, social security payments or other income) with the person in question #1 that has a Lifeline-discounted services? Yes No
A household is not permitted to receive Lifeline benefits from multiple providers. This includes both wireline and wireless providers. Violation of the one-per-household limitation constitutes a violation of the Lifeline rules and will result in the subscriber’s de-enrollment from the program and potentially prosecution by the US government. Lifeline is a non-transferable benefit and the subscriber may not transfer his or her benefit to any other person.
Contact Information
*First Name *Last Name
*Service Address Line 1 *Service Address Line 2
*City *State
*Zipcode
*Telephone (###-###-####) * Date of Birth (mm/dd/yyyy)
* Last 4 digits of Social Security Number (The last four digits of your Social Security Number are required to complete this application. If you do not wish to provide this information here, please apply for Lifeline directly through your Service Provider.) Service Provider
I hereby certify that I participate in the following public assistance program(s):
  Medicaid
  SNAP
Checked if Different Billing

I certify, that:

I will notify my Lifeline provider within 30 days if I no longer participate in a qualifying DCF assistance program, if I receive more than one Lifeline benefit, or if another member of my household is receiving a Lifeline benefit;

If I move to a new address, I will provide that new address to my Lifeline provider within 30 days;

My household will receive only one Lifeline service and, to the best of my knowledge, my household is not already receiving a Lifeline service;

The information contained in this application is true and correct to the best of my knowledge;

I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law; and,

I acknowledge that I may be required by my Lifeline provider to recertify my continued eligibility for Lifeline at any time, and my failure to re-certify as to my continued eligibility will result in deenrollment and the termination of my Lifeline benefits.

I understand that my name, telephone number, and address may be provided to the Universal Service Administrative Company (USAC) (the administrator of the program) and/or its agents for the purpose of verifying that my household does not receive more than one Lifeline benefit and for proper administration of the program.

I agree to allow exchange of any necessary information between the local telephone company, the appropriate federal or state agency, or fund administrator, to verify my eligibility to participate in the Lifeline discount program. I give this permission on the condition that the information in this form and any information about my participation in the above public assistance programs provided by officials be maintained as confidential customer account information.

I agree to these terms and conditions:
Yes   No

Date (mm/dd/yyyy)