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 YOU LEARNED ABOUT LIFELINE/LINK-UP: ___________________________ COMPLETED APPLICATION FORMS SHOULD BE SUBMITTED DIRECTLY TO LOCAL TELEPHONE SERVICE UTILITIES. 9/06 ------------------------------------------- For more information, call your local telephone company. Indiana Telephone Assistance Program providers: AT&T Indiana (formerly SBC) 1-888-285-7983 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. (TDS) 1-888-225-5837 Communications Corp. of So. Ind. (TDS) 1-888-225-5837 Craigville Telephone 1-260-565-3131 Daviess Martin Co. Rural Coop. 1-812-486-3211 Embarq (formerly Sprint) 1-800-257-3212 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 SEI Data 1-812-667-5100 Smithville Telephone 1-812-876-2211 Southeastern Ind. Rural Telephone Coop. 1-888-200-8077 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 January 2006)