Article Structure
The Application Verizon Lifeline form is designed to facilitate access to vital telecommunications services for eligible low-income individuals and families. This comprehensive document encompasses various sections aimed at gathering essential information about the applicant, their residential and billing addresses, and their current household composition. Applicants are required to confirm their eligibility by indicating participation in certain public assistance programs such as Medicaid or Food Stamps, or by providing proof of household income that falls below specified federal poverty guidelines. Additional requirements apply specifically to residents of Tribal lands, necessitating separate documentation for those seeking benefits under Link Up assistance. The form also outlines numerous certifications that applicants must initial to assert eligibility and compliance with the Lifeline program's rules. To ensure the verification process runs smoothly, applicants must submit two forms of identification, which reinforce their claims and facilitate the speedy initiation of Lifeline services, potentially reducing their monthly telecommunications costs significantly.
Application Verizon Lifeline Example
LIFELINE ASSISTANCE APPLICATION FORM
VERIZON USE ONLY: New Customer |
Annual Recertification |
SECTION 1 – APPLICANT
NY
Name:
(First)(Middle)(Last)
Residential Address: |
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NY |
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(Cannot be a P.O. Box; must |
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(Street) |
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(City) |
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(Apt #) |
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be your physical address) |
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Please indicate if the address listed above is a temporary residential address: (please check one) |
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Yes |
No |
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Billing Address: |
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NY |
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(If not the same as your residential address) (Street) |
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(City) |
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(Apt #) |
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(State) |
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(ZIP) |
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Wireless Phone Number (if existing customer): ( |
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Number of Persons in Household: |
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Phone number where you can be reached to discuss this application form: ( |
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Date of Birth: |
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Last four (4) digits of your Social Security # (or complete Tribal Government ID#): |
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I, or a member of my household, currently receives Lifeline at the above residential address:
Yes (You are not eligible for Lifeline.) No
I, or a member of my household, has received Link Up at the above residential address: (For eligible residents of Tribal lands only)
Yes (You are not eligible for Link Up.) No
SECTION 2 – ELIGIBILITY FOR LIFELINE ASSISTANCE
NEW CUSTOMERS: If you qualify based on participation in one of the public assistance programs listed below, you must provide a copy of documentation demonstrating your participation in the program.
EXISTING LIFELINE CUSTOMERS: If you are recertifying your eligibility you do not need to provide these documents.
I am, or my dependant(s) are or a member of my household is, currently receiving benefits from one of the following public assistance program(s):
Food Stamps/Supplemental Nutrition Assistance Program (SNAP) |
National School Lunch Program’s free lunch program |
Medicaid (not Medicare) |
(must qualify for free lunch) |
Federal Public Housing Assistance (including Section 8) |
Supplemental Security Income (SSI) |
Low Income Home Energy Assistance (LIHEAP) |
Safety Net Assistance |
Temporary Assistance for Needy Families (TANF) |
Veterans Disability Pension |
Family Assistance |
Veterans Surviving Spouse Pension |
OR
My total household income is at or below 135% of the Federal Poverty Guidelines.
If you qualify based on total household income, you must provide copies of one of the documents below:
Prior year’s State, Federal or Tribal Tax Return |
Retirement/Pension Benefit Statements |
Social Security Benefits Statements |
Divorce Decree or Child Support Documents |
Veterans Administration Benefits Statements |
Unemployment/Workers Compensation Benefits Statements |
Federal or Tribal notice letter of participation in |
Current Income Statements from Employer or Paycheck Stubs |
Bureau of Indian Affairs General Assistance |
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If you provide documentation that does not cover a full year (such as current paycheck stubs), you must submit three (3) consecutive months’ worth of the same type of document from the previous twelve months.
SECTION 3 – RESIDENTS OF TRIBAL LANDS MUST COMPLETE SECTIONS 2 AND 3 (CHECK ALL THAT APPLY)
My residential address is located on federally recognized Tribal lands.
I am, or my dependant(s) are or a member of my household is, currently receiving benefits from one of the public assistance programs in Section 2 and/or from one of the following program(s):
Head Start (must satisfy income qualifying standard) |
Bureau of Indian Affairs General Assistance |
Tribally Administered Temporary Assistance for Needy Families (TANF) Food Distribution Program on Indian Reservations
©2014 Verizon Wireless |
LFLKFRMNY0314EN |
LIFELINE ASSISTANCE APPLICATION FORM
NY
SECTION 4 – APPLICANT CERTIFICATION AND AGREEMENT
Lifeline is a federal benefit and willfully making false statements to obtain Lifeline can result in fines, imprisonment,
EACH OF THE FOLLOWING CERTIFICATIONS MUST BE INITIALED IN ORDER TO RECEIVE LIFELINE.
I CERTIFY UNDER PENALTY OF PERJURY:
That I meet the
That I will notify Verizon Wireless within 30 days if I no longer meet the
That if I am seeking to qualify for Lifeline as an eligible resident of Tribal lands, I live on Tribal land.
That if I move to a new address, I will provide my new residential address to Verizon Wireless within 30 days.
That my household will receive only one Lifeline discount and, to the best of my knowledge, my household is not already receiving a Lifeline discount.
That the information contained in this certification form is true and correct to the best of my knowledge.
That I acknowledge that providing false or fraudulent information to receive Lifeline is punishable by law and may subject me to fines, imprisonment or being barred from the program.
That I acknowledge that I may be required to recertify my continued eligibility for Lifeline at
CUSTOMER INITIALS
CUSTOMER INITIALS
CUSTOMER INITIALS
CUSTOMER INITIALS
CUSTOMER INITIALS
CUSTOMER INITIALS
CUSTOMER INITIALS
any time, and that failure to do so within 30 days will result in termination of my Lifeline discount.
CUSTOMER INITIALS
I provide my consent for Verizon Wireless to send the information below to the Universal Service Administrative Company (USAC) and/or its agents for the purpose of verifying that I do not receive more than one Lifeline discount. If USAC determines that I am receiving more than one Lifeline discount then all Lifeline providers involved may be notified so that I may select one Lifeline provider and be
• My full name |
• The date on which Lifeline service was initiated |
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• My full residential address |
• The date on which Lifeline service was terminated, |
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• My date of birth |
if it has been terminated |
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• The amount of my Lifeline discount |
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• The last four digits of my social security number or |
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my complete Tribal Identification number |
• The means through which I qualified for Lifeline |
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• My telephone number associated with Lifeline service |
CUSTOMER INITIALS |
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©2014 Verizon Wireless |
LFLKFRMNY0314EN |
LIFELINE ASSISTANCE APPLICATION FORM
NY
I authorize Verizon Wireless or its authorized representatives to access any records (including financial records) required to verify my statements herein, and to obtain and use my credit as necessary to set up an account, although credit history will not impact eligibility for Lifeline or Tribal Link Up. I authorize social service agency representatives to provide information to Verizon Wireless verifying my eligibility for, or participation in, a qualifying public assistance program.
I authorize Verizon Wireless to release any records (including financial records) required for the administration of the Lifeline program.
I understand the terms of the Verizon Wireless Lifeline plans and authorize Verizon Wireless to make any changes necessary to my account in order to activate or implement the Verizon Wireless Lifeline plans.
I agree to the current Verizon Wireless Customer Agreement, including the Plan, and other terms and conditions for services and selected features I have agreed to purchase, and which have been presented to me by the Sales Representative, and which I had the opportunity to review. I understand that I am agreeing to limitations of liability for service and equipment, settlement of disputes by arbitration and other means instead of jury trials and other important terms in the Customer Agreement.
I understand that I must fulfill the terms and conditions of any existing Customer Agreement with Verizon Wireless and that termination of my existing plan to activate Lifeline service may result in the assessment of a termination fee.
TWO FORMS OF IDENTIFICATION WILL BE REQUIRED TO PROCESS YOUR APPLICATION (ONE PRIMARY, ONE SUPPLEMENTAL): Primary ID: State issued Driver’s License or ID, US Passport, Tribal Card, Resident Alien Card, US Visa, etc.
Supplemental ID: Public Utility Bill, Credit Card Bill, Computerized Paycheck Stub, Social Security Card, Voter Registration Card, Vehicle Registration Card, Bank Statement, County ID, etc.
SIGNATURE: |
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DATED: |
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, 20 |
LIFELINE ASSISTANCE
•Qualifying customers will save $9.25 per month off of the monthly access charge. Qualified residents of federally recognized Tribal lands may receive up to $25 in additional Lifeline discounts per month.
•You will not be charged a service deposit to initiate Lifeline. However, you may be required to bring your account current if you incur charges materially in excess of your monthly access. Failure to bring your account current may result in a suspension or termination of your service.
•Your equipment charges will appear on your first month’s bill unless you will be using equipment that has previously been paid for and is compatible with the Verizon Wireless network.
•International Long Distance is not a part of the Lifeline plans. Your Lifeline device may not be used to make International Long Distance calls. Access to “900” numbers is prohibited. Use of the service to make prohibited calls can result in the curtailment or termination of service.
•Your first bill will include one full month’s access charge in advance and a portion of the current month’s access charge which is calculated based on the activation date. Your Lifeline discount will also be applied accordingly.
•The Lifeline discount is limited to a single line of service. You may not apply for multiple Lifeline discounts and must choose to apply your Lifeline discount to either a landline or wireless number, but not both. Please note that other service providers may use terms other than “Lifeline” to describe the Lifeline program. By signing this application, you are certifying, under penalty of perjury, that you will comply with this requirement. Lifeline is only available to a subscriber whose residential address is located within Verizon Wireless’ Lifeline service area. Lifeline may not be applied retroactively.
•You must pay all sales, excise and other taxes and governmental surcharges and fees that we are required by law to bill customers. These taxes, surcharges and fees may change from time to time without notice. However, Lifeline subscribers will not be assessed a Federal Universal Service Fund or Regulatory charge.
•Other restrictions may apply.
IF YOU CHOOSE THE $3399 LIFELINE PLAN, IT INCLUDES:
•Basic Voice Mail with Message Waiting Indicator, Caller ID, Call Waiting,
•400 Anytime Minutes and 1,000 Mobile to Mobile Calling minutes within the Local Coverage Area. A charge of 45¢ per minute applies to incoming and outgoing calls made after the allowance is exhausted. Roaming outside the Local Coverage Area is prohibited. The plan does not include Nights & Weekends.
©2014 Verizon Wireless |
LFLKFRMNY0314EN |
LIFELINE ASSISTANCE APPLICATION FORM
NY
•Domestic Long Distance calls made from your wireless phone while you are within your Local Coverage Area. Airtime charges apply. Domestic Long Distance includes calls made from within your Local Coverage Area to anywhere within the United States or Puerto Rico.
IF YOU CHOOSE THE $1999 HOME PHONE CONNECT PLAN, IT INCLUDES:
•Basic Voice Mail, Caller ID (number only), Call Waiting,
•Unlimited
fax machines and some home security systems. For more information please call 1.800.417.3849.
•Domestic Long Distance calls made while you are within your Local Coverage Area to anywhere within the United States or Puerto Rico.
•The Home Phone Connect Family SharePlan® is not available as part of Lifeline.
LINK UP ASSISTANCE
Qualifying customers that reside on federally recognized Tribal lands may be eligible for Link Up, which is a 100% reduction of Verizon Wireless’ customary activation charge of $35. Link Up is only available to a subscriber whose residential address is located on a federally recognized Tribal land that is within Verizon Wireless’ designated service area. Link Up may only be applied once to initiate service (for a single landline or wireless telephone line) at the same address. Link Up cannot be applied to customer facilities or equipment, including the cost of your phone. Link Up may not be applied retroactively.
135% OF THE FEDERAL POVERTY GUIDELINES – 2014
Persons in Family or Household |
48 Contiguous States and D.C. |
1 |
$15,755 |
2 |
$21,236 |
3 |
$26,717 |
4 |
$32,198 |
5 |
$37,679 |
6 |
$43,160 |
7 |
$48,641 |
8 |
$54,122 |
For Each Additional Person Add |
$5,481 |
THIS FORM MUST BE COMPLETED IN ITS ENTIRETY. THE COMPLETED APPLICATION, TWO FORMS OF ID, AND PROOF OF BENEFITS CAN BE FAXED TO:
1.877.561.7829
OR CAN BE MAILED TO:
Verizon Wireless c/o CORe Department 2nd Floor
3601 Converse Drive
Wilmington, NC 28403
IF YOU HAVE QUESTIONS, PLEASE CALL 1.800.417.3849 FOR ASSISTANCE.
Verizon Wireless Use Only
Name:
Email for Confirmation:
CBR:
Rate Plan:
Tribal Plan:
Equipment Type:
ESN:
Phone User (Authorized on Account for Equipment Issues Only):
Office Use Only
Application Number:
Account Number:
Representative Name:
MTN:
Date Completed:
Eligibility Documents Received:
©2014 Verizon Wireless |
LFLKFRMNY0314EN |
Form Characteristics
| Fact Name | Description |
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| Eligibility Criteria | To qualify for the Lifeline assistance program, applicants may demonstrate eligibility through participation in specific public assistance programs or by meeting income guidelines. Documentation may be required for new applicants. |
| One Discount Per Household | The Lifeline discount is limited to one per household. A household is defined as people living together at the same address who share income and expenses. |
| Proof of Identification | Applicants must provide two forms of identification: one primary (e.g., driver's license, passport) and one supplemental (e.g., utility bill, paycheck stub) to process the application. |
| Federal Law Governing Lifeline | The Lifeline program is governed by regulations enforced by the Federal Communications Commission (FCC). It aims to ensure affordable access to telecommunications services for low-income households. |
| Application Submission | Applications must be completed in full and submitted with required documentation. Options for submission include faxing to 1.877.561.7829 or mailing to the designated Verizon address in Wilmington, NC. |
Guidelines on Utilizing Application Verizon Lifeline
Completing the Application for Verizon Lifeline can be straightforward if approached step by step. Be sure to gather all necessary documents beforehand to streamline the process. Below are clear instructions to assist you in filling out the form accurately.
- Select the appropriate option indicating if you are a new customer or recertifying.
- In Section 1, fill in your name (first, middle, and last) and your residential address. Note that it must not be a P.O. Box but rather your physical address.
- Indicate whether the residential address is temporary by checking Yes or No.
- If your billing address differs from your residential address, provide that information as well.
- Provide your wireless phone number if you're an existing customer.
- Specify the number of people living in your household and a phone number where you can be contacted.
- Enter your date of birth and the last four digits of your Social Security number or complete Tribal Government ID number.
- Answer the questions regarding your current Lifeline status and Link Up benefits with Yes or No.
- Move to Section 2 and check the public assistance programs from which you or a household member receive benefits. Provide documentation if applicable.
- Alternatively, if qualification is based on income, check the relevant box and prepare to submit the necessary income documentation.
- If living on Tribal lands, complete Section 3 by checking all relevant boxes concerning your address and assistance programs.
- In Section 4, read the applicant certification carefully. Initial beside each statement to affirm your understanding and compliance.
- Prepare two forms of identification: one primary (like a state-issued ID or passport) and one supplemental (such as a utility bill or bank statement).
- Finally, sign and date the application to verify all information is accurate.
Once your application is complete, you may fax it to 1.877.561.7829 or mail it to the provided address. Should you have any questions during this process, assistance is available by calling 1.800.417.3849.
What You Should Know About This Form
1. What is the Verizon Lifeline program?
The Verizon Lifeline program provides discounts on monthly phone service for eligible low-income consumers. It aims to ensure that all individuals have access to basic telecommunication services. Qualifying customers can receive a discount of $9.25 per month, and those on Tribal lands may qualify for an additional $25 discount each month.
2. Who is eligible to apply for the Lifeline program?
Eligibility is based on either participation in specific public assistance programs or meeting income guidelines. Programs include Medicaid, SNAP, and federal housing assistance, among others. Alternatively, if a household's income is at or below 135% of the Federal Poverty Guidelines, they may qualify.
3. What documents are required to apply?
Applicants must provide evidence of either their participation in public assistance programs or documentation that verifies their income. This includes tax returns, benefit statements, or pay stubs, depending on how they qualify. For new customers, two forms of identification—one primary and one supplemental—are also required.
4. How many Lifeline discounts can a household receive?
A household is only permitted to receive one Lifeline discount, regardless of the number of individuals living at the address. This ensures that the program serves as many unique households as possible. Violating this rule may lead to removal from the program.
5. How do I apply for Lifeline assistance?
To apply, individuals must complete the Lifeline Assistance Application Form. This form must be filled out accurately, including personal details and proof of eligibility. Once completed, the application can be submitted via fax or mail to the designated Verizon Wireless addresses provided in the form.
6. Can I transfer my Lifeline discount to someone else?
No, the Lifeline discount is non-transferable. It is designed to be linked to the qualifying individual's residence. If a recipient moves or no longer qualifies, they must notify Verizon Wireless of the change immediately.
7. What happens if I stop qualifying for Lifeline?
If a recipient no longer meets the eligibility criteria, they are required to inform Verizon within 30 days. Failure to do so may result in losing the Lifeline discount and lead to potential legal implications if false information has been provided.
8. Are there any costs associated with the Lifeline program?
While there is no service deposit for initiating Lifeline, customers are responsible for applicable taxes, surcharges, and fees. Additionally, the first month's bill will include a full access charge based on service activation and any necessary equipment charges.
9. What services are included with the Lifeline discount?
The Lifeline plan includes essential services such as voicemail, caller ID, call waiting, and limited call minutes based on the chosen plan. Optional services like data and text messaging are not available within the Lifeline offerings. Customers should review their specific plan details carefully to understand what is included.
Common mistakes
When applying for the Verizon Lifeline program, individuals may encounter several common mistakes that can hinder the application process. One frequent error is not providing the correct residential address. The address must be a physical location and cannot be a P.O. Box. Failing to meet this requirement can lead to automatic rejection of the application.
Another common mistake is neglecting to indicate whether the listed address is temporary. Applicants often overlook this detail, which may impact their eligibility. Checking 'Yes' or 'No' is essential for processing the application properly.
Incomplete contact information can also create issues. It is crucial to provide a reachable phone number to discuss the application. If this information is missing or inaccurate, it may slow down or cancel the application altogether.
Participants may also misunderstand the documentation requirements based on their eligibility criteria. New customers qualifying through public assistance must submit evidence of participation in a program. Not including appropriate documentation can delay the approval of the Lifeline benefit.
Providing false or incomplete information raises significant red flags. A common mistake is not thoroughly reviewing the certification section before signing. All certifications must be initialed to confirm understanding and compliance with Lifeline requirements.
Another issue arises when applicants fail to submit two forms of identification. One must be primary, such as a state-issued ID, and the other can be a utility bill or bank statement. Missing either of these can lead to application denial.
Lastly, individuals may overlook the importance of submitting the entire application. Incomplete forms result in processing delays or outright rejection. Carefully reviewing the application helps ensure that all sections are filled out accurately and completely before submission.
Documents used along the form
The Application Verizon Lifeline form is an essential document used by individuals seeking assistance through the Lifeline program. Along with this application form, certain other documents are commonly required to validate eligibility and facilitate the application process. Below is a list of relevant forms and documents that are often needed.
- Proof of Participation in Public Assistance Programs: Applicants qualifying for Lifeline based on public assistance must provide documentation showing their participation in programs such as Food Stamps or Medicaid. This could include a benefit statement or letter confirming active enrollment.
- Income Documentation: Individuals claiming eligibility based on household income need to submit recent financial documents. Acceptable items include tax returns, Social Security statements, or paycheck stubs that demonstrate income levels at or below 135% of the federal poverty guidelines.
- Identification Documents: Two forms of ID are required when submitting the application. One should be a primary ID, like a state-issued driver’s license or U.S. passport, while a supplemental ID can be a utility bill or bank statement that confirms the applicant's residential address.
- Eligibility Certification: This is a signed statement affirming that the applicant meets the income or program-based criteria outlined in the Lifeline program. It reaffirms that all information provided is true and accurate under penalty of
Similar forms
Food Stamp/SNAP Application: Like the Verizon Lifeline application, this document requires personal identification information and income verification. Applicants must provide proof of income or indicate participation in specific assistance programs, ensuring that both processes serve individuals seeking financial assistance based on need.
Medicaid Application: The Medicaid application shares similarities with the Lifeline application in its comprehensive data collection. Both forms require the applicant to disclose personal information, household size, and income levels, reflecting the applicant’s eligibility for assistance based on participation in public welfare programs.
Low-Income Home Energy Assistance Program (LIHEAP) Application: This document mirrors the Lifeline application by assessing eligibility through income documentation or current assistance program participation. Both applications involve rigorous verification of income and household dynamics.
Supplemental Security Income (SSI) Application: The SSI application is comparable, requiring individuals to submit proof of income, age, or disability. Just as with the Lifeline application, the focus here is on verifying the financial and situational status of applicants to determine eligibility for benefits.
Temporary Assistance for Needy Families (TANF) Application: This application shares structural elements with the Lifeline form, particularly in evaluating a household’s financial situation. Both require extensive personal information and encourage applicants to demonstrate financial hardship through documented evidence.
Dos and Don'ts
When filling out the Verizon Lifeline Application form, it’s crucial to approach the process with care. Follow these guidelines to ensure a smooth application experience.
- Do: Provide your full name and accurate residential address. Remember, the address must be your physical residence, not a P.O. Box.
- Do: Indicate if your residence is temporary, if applicable. This helps Verizon understand your situation more clearly.
- Do: Include any required documentation that verifies your participation in public assistance programs. This can streamline your application significantly.
- Do: Make sure to use a contact phone number where you can be reached. Open communication can expedite any follow-up needed.
- Do: Carefully review the eligibility criteria. Ensure you meet the income or program-based requirements before applying.
- Don't: Forget to double-check all information for accuracy. Mistakes can delay your application or result in denial.
- Don't: Provide any false information on the application. Consequences can include penalties or being barred from receiving Lifeline benefits.
- Don't: Assume that you qualify based on income without checking. It's essential to determine if your total household income meets the specified guidelines.
- Don't: Skip the signatures or initials required for certification. Each section must be confirmed by you for the application to be valid.
- Don't: Submit incomplete documentation. Ensure that you provide both primary and supplemental identification as required.
By adhering to these tips, you can help ensure that your application is processed efficiently and accurately.
Misconceptions
- Misconception 1: Lifeline is only for households already in poverty.
- Misconception 2: Only one type of service can receive Lifeline support.
- Misconception 3: You must provide extensive documentation every time you apply.
- Misconception 4: The application process is overly complicated and time-consuming.
- Misconception 5: You can receive multiple Lifeline discounts in the same household.
- Misconception 6: Lifeline discounts are retroactive and can be applied to past bills.
While many Lifeline applicants may indeed be in financial need, it is also available for households that qualify based on participation in various public assistance programs. Participants in programs such as SNAP or Medicaid can apply.
This is partially true; you can apply Lifeline benefits to either a landline or wireless service but not both at the same time. However, many might assume this means they should not apply if they already use one type of service, when they could still receive support.
New Lifeline applicants need to submit proof of their participation in a qualifying program or financial status. Existing customers just need to recertify, which does not require resubmitting documents if their eligibility remains the same.
While some may feel daunted by the forms and requirements, the application can be straightforward. Following the instructions step-by-step simplifies the process significantly.
In reality, only one Lifeline discount is permitted per household. Any violation can lead to penalties, including being barred from the program. This rule helps ensure that assistance reaches those in need without duplication.
This is incorrect. Lifeline discounts begin only from the date the application is approved and cannot be applied to previous charges. Therefore, timely application is essential.
Key takeaways
When filling out and utilizing the Verizon Lifeline Application form, it's important to keep the following key points in mind:
- Eligibility Criteria: Applicants must demonstrate eligibility through participation in specific public assistance programs or by providing income documentation.
- Identification Requirements: Two forms of identification are required to process the application—one primary and one supplemental. Acceptable forms are clearly listed in the application.
- Address Accuracy: The residential address must be physical and cannot be a P.O. Box. This address determines eligibility for the Lifeline program.
- Recertification: Existing Lifeline customers must recertify their eligibility annually. However, they do not need to provide supporting documents during the recertification process.
- One Discount Per Household: Only one Lifeline discount is available per household. Sharing the discount or applying for multiple discounts will lead to disqualification.
- Non-Retroactive Discounts: Discounts cannot be applied retroactively, so it is necessary to complete the application accurately and promptly for potential benefits.
Understanding these key takeaways can simplify the application process and help ensure compliance with program rules.
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