APPLICATION
FOR LIFELINE AND/OR LINK-UP TELEPHONE SERVICE
Eligibility for Lifeline and/or Link-Up Telephone Service is dependent on Applicant's participation in one or more of the programs listed below.
1. I hereby certify that I participate in the following programs (check all that apply):
____ Federal Public Housing Assistance or Section 8
____ Food Stamps
____ Low Income Home Energy Assistance Program (LIHEAP)
____ Medicaid
____ National School Free Lunch Program
____ Supplemental Security Income
____ Temporary Assistance for Needy Families (TANF)
2. ____ I certify that I qualify because my annual household income is at or below 135% of Federal Poverty Guidelines.
3. I also hereby certify that:
- My telephone service is listed in my name;
- I am not listed as a dependent on another person's tax return;
- The address listed is my primary residence; not a second home or business; and
4. If in the future I no longer participate in at least one of the programs listed in item 1 above or conditions in item 2 above change, I will promptly notify my local telephone company that I am no longer eligible for Lifeline and/or Link-Up Telephone Service.
5. I authorize my local telephone company or its duly appointed representative to access any records required to verify these statements to confirm my continued participation in the above programs. I authorize representatives of the above programs to discuss with and/or provide copies to my local telephone company, if requested by the company, to verify my participation in the above programs and my eligibility for Lifeline or Link-Up Telephone Service.
6. I (we) affirm, under penalty of perjury, that the foregoing representations are true.
APPLICANT'S NAME: ______________________________________________
SERVICE ADDRESS: ______________________________________________
(Street)
________________________________________________________________
(City) (State) (Zip Code)
TELEPHONE NUMBER (if already established):_______________________
APPLICANT'S SIGNATURE:_________________________________ DATE: ________________________
HOW DID YOU LEARN ABOUT LIFELINE/LINK-UP: __________________________________________
COMPLETED APPLICATION FORMS SHOULD BE SUBMITTED DIRECTLY TO LOCAL TELEPHONE SERVICE UTILITIES.
9/05
For more information, call your local telephone company.
Indiana Telephone Assistance Program providers:
Bloomingdale Home Telephone 1-765-498-2000
Camden Telephone (TDS) 1-888-225-5837
Centennial Wireless 1-800-493-3121
Century Telecom of Central Ind. 1-800-201-4099
Century Telecom of Odon 1-800-201-4099
Citizens Telephone 1-260-375-2111
Clay County Rural Telephone Coop. 1-800-922-6677
Communications Corp. of Ind. 1-888-225-5837
Communications Corp. of So. Ind. 1-888-225-5837
Craigville Telephone 1-260-565-3131
Daviess Martin Co. Rural Coop. 1-812-486-3211
Frontier Comm. of Ind. 1-800-921-8101
Frontier Comm. of Thorntown 1-800-921-8101
Geetingsville Telephone 1-765-258-3111
Hancock Communications 1-317-477-1234
Hancock Rural Telecom 1-317-477-1234
Home Telephone of Pittsboro (TDS) 1-888-225-5837
Home Telephone (TDS) 1-888-225-5837
Ligonier Telephone 1-800-714-6353
Merchants & Farmers Telephone 1-888-225-5837
Monon Telephone 1-800-531-7121
Mulberry Telephone 1-765-296-2885
Nextel Partners 1-888-556-6111
New Lisbon Telephone 1-765-332-2885
New Paris Telephone 1-888-831-4678
Northwestern Ind. Telephone (NITCO) 1-219-996-2981
Perry-Spencer Telephone 1-812-357-2123
Pulaski-White Telephone 1-800-760-0848
Rochester Telephone 1-574-223-2191
SBC 1-888-285-7983
SEI Data 1-812-667-5100
Smithville Telephone 1-812-876-2211
Southeastern Ind. Rural Telephone Coop. 1-888-200-8077
Sprint 1-800-877-4646
Sprint PCS 1-888-211-4727
Sunman Telephone 1-812-623-2122
Swayzee Telephone 1-765-922-7916
Sweetser Telephone 1-765-384-4311
S&W Telephone (TDS) 1-888-225-5837
Tipton Telephone (TDS) 1-888-225-5837
Tri-County Telephone (TDS) 1-888-225-5837
Verizon 1-800-483-3000
Washington Telephone 1-812-967-3171
West Point Telephone 1-765-572-2488
Yeoman Telephone 1-574-965-2100
(List current as of July 2005)