Monon Telephone Co. Inc.â
Link-Up and Lifeline Programs Application
Page 1 of 3
Link-Up and Lifeline are plans that assist lower-income consumers obtain basic telephone service by providing discounted connection rates and reduced monthly subscription charges. In addition, connection charges can be paid in installments, without interest. You are eligible for these discounts if you participate in or receive benefits from certain government aid programs, or if your household income meets certain requirements. If you have any questions, please call us at 219-253-6601, and ask to speak with a Customer Service Representative.
Please print or type the following information:
Name: _________________________________________________________________________ (Last) (First) (Middle) Address: _______________________________________________________________________ (Street and house/apartment number) (City) (State) (Zip)
Social Security Number: ________________________
Phone Number Where You Can Be Reached or Receive Messages: ________________________
I am requesting ___________ Link-Up and/or _______________ Lifeline
Have you previously received telephone connection at the address listed above?
Yes _________ No ___________
Do you participate in any of the following programs?
Medicaid _________
Food Stamps __________
Supplemental Security Income (SSI) _____________
Federal Public Housing Assistance (Section 8) ________________
Low-Income Home Energy Assistance Program (LIHEAP) ____________
Temporary Assistance to Needy Families (TANF) ______________
National School Free Lunch Program (NSL) ________
Monon Telephone Co. Inc.â
Link-Up and Lifeline Programs Application
Page 2 of 3
If you are requesting Link-Up and/or Lifeline on the basis of your household income, then please attach a copy or copies of the following types of documents for each member of your household who may have received such documentation or to whom such documentation may apply. Please "check" the documentation provided.
What is your total annual household income, i.e., the total combined income earned each year by all members of your household? $ ___________________________
How many people reside in your household? ________________
______ Prior year’s state, Federal, or tribal tax return, or
______ Current income statement from an employer or paycheck stub (covering three consecutive months), or
______ Social Security statement of benefits (covering three consecutive months), or
_____ Veterans Administration statement of benefits (covering three consecutive months), or
_____ Retirement/pension statement of benefits (covering three consecutive months), or
_____ Unemployment/Workmen’s Compensation statement of benefits (covering three consecutive months), or
_____ Federal or tribal notice letter of participation in General Assistance, or
_____ Divorce decree, child support, or other official document containing current income information.
Monon Telephone Co. Inc.â
Link-Up and Lifeline Programs Application
Page 3 of 3
Subscriber Information
Phone Number Where You Can Be Reached or Receive Messages: ________________________
* I understand that submission of this completed Application does not guarantee acceptance into either the Link-Up or Lifeline programs.
I certify, under penalty of perjury, that:
* I currently receive benefits from, and agree to notify Monon Telephone Co. Inc.â if I cease to receive benefits from, one or more of the following programs: Medicaid, Food Stamps, Supplemental Security Income (SSI), Federal Public Housing Assistance (Section 8), Low-Income Home Energy Assistance Program (LIHEAP), Temporary Assistance to Needy Families (TANF), National School Free Lunch Program (NSL).
* The information provided by me in regard to this Application is true and correct and represents accurately my household income and the number of people in my household, and I agree to notify Monon Telephone Co. Inc.â within 30 days if my household income increases and/or the number of people in my household decreases in order to confirm with Monon Telephone Co. Inc.â my continuing eligibility for Lifeline services. There are currently ________ people in my household.
FORM BENEATH THIS LINE FOR TELEPHONE COMPANY USE ONLY
I hereby certify under penalty of perjury that Monon Telephone Co. Inc.â has procedures in place to review income documentation and that to the best of my knowledge the carrier was presented with documentation of the Applicant’s household income.
__________________________________________________________________________________________ (Print Name) (Title)This Form to be Retained by Company for Duration of Customer’s Subscription to Lifeline Service
Pages 1 and 2 of this Application to be Destroyed Upon Verification of Subscriber’s Eligibility for Link-Up and/or Lifeline; Customer-Provided Documentation of Eligibility to be Returned to Customer