Lifeline Discount Form

Lifeline is a federal program that provides free or low-cost phone or internet service to low-income households through a monthly service discount.

IDENTIFICATION

First Name *

Last Name *

Email *

Phone *

Electric Bill Account Number *

Address *

Apt/Suite

City *

State *

Zip *

Is your mailing address the same as above? *

Yes

Mailing Address *

Apt/Suite

City *

State *

Zip *

ELIGIBILITY

Applicant must provide proof of eligibility for one of the following programs: *

Select all that apply.

Do you currently receive Fuel Assistance?

Do you currently receive AFDC Assistance?

Do you currently receive Food Stamps?

Are you eligible for Merrimac's Real Estate Exemption?

Are you or your spouse a Disabled Veteran?

Are you or your spouse Disabled?

Upload Document(s) *

SIGNATURE

Signature *

By signing, I confirm that this application has been prepared or examined by me. Under the pains and penalties or perjury, I declare that to the best of my knowledge and belief, it and all accompanying documents and statements are true, correct and complete.

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