APPLICATION FOR LIFELINE AND/OR LINK-UP TELEPHONE SERVICE COMPLETED APPLICATION FORMS SHOULD BE SUBMITTED DIRECTLY TO LOCAL TELEPHONE SERVICE COMPANIES. 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 WITH AREA CODE (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 COMPANIES. 5/11 ------------------------------------------- For more information, call your local telephone company. Indiana Telephone Assistance Program providers: AT&T Indiana 1-888-285-7983 Bloomingdale Home Telephone (765) 498-2000 Centennial Wireless 1-800-493-3121 CenturyLink 1-800-407-5411 Cincinnati Bell (513) 565-2210 Citizens Telephone (260) 375-2111 Craigville Telephone (260) 565-3131 Endeavor Communications 1-888-587-7034 Enhanced Telecommunications Corp. (812) 623-2122 Frontier Communications 1-877-462-8188 Geetingsville Telephone (765) 258-3111 Hancock Telecom (317) 326-3131 Ligonier Telephone 1-800-714-6353 Monon Telephone 1-800-531-7121 Mulberry Telephone (765) 296-2885 New Lisbon Telephone (765) 332-2885 New Paris Telephone (574) 831-6425 NW Ind. Telephone (NITCO) 1-800-996-2981 Perry-Spencer Telephone Coop. (812) 357-2123 Pulaski-White Telephone Coop. 1-800-760-0848 Rochester Telephone (574) 223-2191 RTC Communications (812) 486-3211 SEI Communications 1-888-200-8077 Smithville Telephone (812) 876-2211 Sprint 1-888-408-3306 Swayzee Telephone (765) 922-7916 Sweetser Telephone (765) 384-4311 TDS Telecom 1-888-225-5837 Tele-Media Solutions 1-866-290-1731 Yeoman Telephone (574) 965-2100 (List current as of May 2011)