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Service provided by:

Lifeline Activation /
and Certification Form

Service Request
     Account Number     (If given to you by our rep over the phone)
1. Type of Service

New Service - I don't currently have working service at this address (This government assistance service is available on the primary line ONLY.)
Convert my Existing Number (must have working or suspended service and provide Current Home Phone number below. Also, we cannot convert your existing number if it is a cable company phone line or a VOIP service.)

2. Prior Working Service

If you have had working service at this address within the last 60 days, please provide the following:

Service Provider Name * (i.e. AT&T, or "none" if unknown)
Prior phone number     (###-###-####)

3. Choose a plan

A. Premier Pack ($35/mo, Call Waiting, Caller ID, Unlimited Long Distance, $25 Connection fee due prior to activation.)


Customer Information
  • First Name:
    *
  • Middle Init:
  • Last Name:
    *
Last 4 Digits of SSN:
(or Tribal ID)
Date of Birth:   (mm/dd/yyyy)
Current Home Phone:   (###-###-####)
Contact Phone Num:   (###-###-####)
eMail Address:   *Required fields
 
Residence Address:
  • Address: (no PO Boxes. Must be your principal address)
    *
  • Address (Apt, Suite, Lot, etc):
  • City:
    *
  • State:
    NC
  • Zip:
    *  
This address is:
 
Billing Address:(If different from above. May contain PO Box)
  • Mailing Address:
  • Mailing Address (Apt, Suite, etc):
  • Mailing City:
  • Mailing State:
  • Mailing Zip:
Would you like to receive texts or emails from our company about new service offerings or promotions? (This information will be for company use only and will not be shared with a third party company or organization.)
Eligibility for Lifeline.
Do you or any member of your household currently receive Lifeline assistance at the above address? 
Choose all programs below that you currently participate in (must pick at least one). You must provide proof of participation in one of the programs that you choose.












There are   individuals in my household.(If Income... is checked)
If the beneficiary of the above program is different from the applicant, please state the name of the person receiving the benefit.

I hereby certify that the recipient of the above government program lives in my household and does not receive Lifeline benefits from any other carrier.
Lifeline Authorization and Certifications (All Required)
Please read and certify the following statements by checking the boxes below:
I authorize LTS  to be my local and long distance carrier for the number I am converting (or to be issued). I also understand that I will be billed for my telephone service by LTS.
I hereby authorize the Company to access any records required to verify my statements on this form and to confirm my eligibility for the Lifeline program. I also authorize the Company to release any records required for the administration of the Lifeline program (e.g., name, telephone number and address), including to the Universal Service Administrative Company, to be used in a Lifeline eligibility database and to ensure the proper administration of the Lifeline Program. Failure to consent will result in denial of service.
I hereby certify, under penalty of perjury that:
I meet the Income-based or Program-based eligibility criteria for receiving Lifeline service and have provided (or will provide) documentation of eligibility if required.
I will notify the Company within 30 days if for any reason I no longer satisfy the criteria for receiving Lifeline including, as relevant, if I no longer meet the income-based or program-based eligibility criteria, I begin receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline benefit. I understand that I may be subject to penalties if I fail to follow this requirement.
I am not listed as a dependent on another person's tax return (unless over the age of 60).
If I move to a new address, I will provide that new address to the Company within 30 days.
If I provided a temporary residential address to the Company, I will verify my temporary residential address every 90 days.
I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law.
I acknowledge that I may be required to re-certify my continued eligibility for Lifeline at any time, and my failure to re-certify as to my continued eligibility within 30 days will result in de-enrollment and the termination of my Lifeline benefits.
The information contained in this certification form is true and correct to the best of my knowledge.
Lifeline Certifications (optional)
Please read the following optional statements. Check the ones that apply to you:
Tribal Eligibility:
I hereby certify that I reside on Federally-recognized Tribal lands.
Multiple households sharing an address:
I hereby certify that I reside at an address occupied by multiple households, including adults who do not contribute income to my household and/or share in my household’s expenses, and I will complete a separate additional form.

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