Lifeline Application Form

Lifeline Applications Form

Application Date(Required)

Your Account Number(Required)

Please provide account number that is on your current bill.

What is your Lifeline ID Number?(Required)

Please provide the FCC Lifeline ID Number that was given to you when you enrolled.

HOW did you Qualify for Lifeline Service?(Required)

SNAP (Supplemental Nutrition Assistance Program)

Medicaid

Supplemental Security Income (SSI)

Federal Public Housing Assistance

Veterans Pension and Survivors Benefits Program

You do not participate in one of the following programs, and want to qualify through income

You are not in any of these programs, but you child/children or dependent is in one of these listed programs

Please select one of the following.

Benefit Qualifying Person (BQP) Name(Required)

First Middle Last

BQP Date of Birth

Please Fill in your year of birth.

Customer Name(Required)

First Middle Last

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Telephone Number (Home and/or Mobile)(Required)

Subscriber Consent

- Lifeline provides a discount of up to $9.25 or $5.25 per month depending on service tier or bundle. I will be responsible for the remaining balance after the Lifeline discount is applied. This includes any taxes and required fees that are applied to the full amount of the service.(Required)

- I am either a current Lifeline customer or my eligibility has been verified by the National Lifeline Verifier so that I qualify for the Lifeline.(Required)

- My household may obtain broadband service supported by the Lifeline from any participating provider of my choosing and I may transfer my Lifeline benefit to another provider at any time.(Required)

- I may only receive one Lifeline benefit per household, from one participating provider, and I certify that no other member of my household is receiving Lifeline.(Required)

- All official communications for Lifeline will be via electronic mail or text messaging and I consent to receive such communications from Gearheart Fiber, Inter Mountain Cable, Gearheart TV, Gearheart Fiber, Coalfields & Mikrotec CATV(Required)

- I agree that all information I provide on this form may be collected, used, shared, and retained for the purposes of applying for and/or receiving the Lifeline benefits.(Required)

- Any Benefit Qualifying Person (BQP) can only qualify for one household. (Required)(Required)

Signature Needed to Complete Application

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Lifeline Applications Form

Subscriber Consent

Signature Needed to Complete Application

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