RULES

*If you qualify, your household can receive a monthly Lifeline benefit of up to $9.25 to lower the costs of phone or internet service.
*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.

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). Complete the Lifeline household worksheet to determine if more than one qualifying household is located at your address. If more than one person in your household participates in Lifeline, you are breaking the FCC’s rules and will lose your benefit.

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

If the Lifeline Program Administrator is not able to validate that you or someone in your household qualify by checking available electronic resources (including eligibility databases for the FCC’s government agency partners), you may need to provide additional documents. For example, you may need to provide an official document that proves your participation in a qualifying government assistance program, your income, or your identity. Please include copies of your proof documentation when you submit your application to speed up processing time.

This signed Lifeline Enrollment Form is required to enroll you in Foothills Communications’ Lifeline Program. The National Verifier, not Foothills Communications, determines your eligibility to receive Lifeline. Only persons who have been determined to be eligible by the National Verifier, should complete this Enrollment Form. If you have not qualified for Lifeline through the National Verifier, please visit www.lifelinesupport.org to apply.

The information you enter on this Enrollment Form must be exactly the same as what you provided to the National Verifier to receive eligibility approval. Submission of this form does not guarantee an immediate Lifeline discount with Foothills Communications.

National Verifier Application ID(Required)

Date of Birth(Required)

Last 4 digits of SSN(Required)

Foothills Communications Phone Number

Foothills Communications Account Number

RESIDENTIAL ADDRESS

Must be a street address (not a P.O. Box) and your principle residence.

Street Address (911 Address)(Required)

Apt

City(Required)

State(Required)

Zip Code(Required)

Mailing Address

Apt

City

State

Untitled

Zip Code

QUALIFICATION THROUGH DEPENDENT

Complete if you qualified in the National Verifier through a child or dependent in your household.

First Name

Middle Initial

Last Name

Date of Birth

Last 4 Digits of Social Security Number

CERTIFICATIONS

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 FCC’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 PRA@fcc.gov. 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. In certain cases, the information in your form may be disclosed to the Department of Justice, court, or other adjudicative body when (a) the Commission; (b) any employee of the Commission; or (c) the United States government, is a party to a proceeding before the body or has an interest in the proceeding.

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, is available at https://www.fcc.gov/managing-director/privacytransparency/ privacy-act-information#systems/.

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.

APPLICANT SIGNATURE

By my electronic signature below, I certify that the information provided above is true and correct, and agree to the above Certifications. I further certify that I have read and understand the above Notices and Disclosures of this Enrollment Form.

Date(Required)

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*You may file complaint against your provider via the FCC Consumer Complaint Center –

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Foothills Communications Lifeline Program Enrollment Form