Lifeline Transfer-In From

LIFELINE TRANSFER-IN APPLICATION

Date of Application(Required)

Account Number(Required)

Inter Mountain Cable, Gearheart Fiber, Coalfields Broadband and/or Mikrotec CATV Billing Account Number that is on your billing statement

Lifeline Identification Number(Required)

Name(Required)

First Last

Benefit Qualifying Person(s)(Required)

First Last

Email(Required)

Enter Email Confirm Email

Your Date of Birth

School Name Associated with Application(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone Number

Mobile Phone Number(Required)

I understand my Lifeline benefit will be applied to my new service and will no longer be applied to service retained from the transfer-out provider.(Required)

I may be subject to the transfer-out provider’s undiscounted rates as a result of the transfer if I elect to maintain service from the transfer-out provider.(Required)

I am aware of the one Lifeline benefit transfer transaction per service month.(Required)

CAPTCHA

LIFELINE TRANSFER-IN APPLICATION

Big News – Gearheart Internet Now Unlimited for ALL our Customers!