Lifeline Consent Form

Lifeline is an FCC program that helps make communications services more affordable for low-income consumers. Lifeline provides subscribers a discount on qualifying monthly telephone service, broadband Internet service, or bundled voice-broadband packages purchased from participating wireline or wireless providers. The discount helps ensure that low-income consumers can afford 21^st century connectivity services and the access they provide to jobs, healthcare, and educational resources.

Lifeline Application Form

Application Date(Required)

Account Number(Required)

Please provide account number that is on your current bill.

What is your Lifeline ID Number?(Required)

Please provide the FCC Lifeline ID Number that was given to you when you enrolled.

How Did You Qualify?(Required)

SNAP (Supplemental Nutrition Assistance Program)

Medicaid

Supplemental Security Income (SSI)

Federal Public Housing Assistance

Veterans Pension and Survivors Benefits Program

You do not participate in one of the following programs, and want to qualify through income

you are not in any of these programs, but your child/children or dependent is in one of these programs

Benefit Qualifying Person (BQP) Name(Required)

First Middle Last

BQP Birthdate(Required)

Please Fill in your year of birth

Customer Name(Required)

First Middle Last

Billing Address(Required)

Street Address Address Line 2 City State (Lifeline only valid in State of Kentucky) ZIP Code

Telephone Number(Required)

Valid Email Address(Required)

Enter Email Confirm Email

Subscriber Consent

GEARHEART LIFELINE PROGRAM QUALIFICATION FORM

By signing this form, I give my affirmative consent that I want to participate in the Affordable Connectivity Program through Gearheart Fiber, Inter Mountain Cable, Coalfields Telephone or Mikrotec CATV and that I understand and certify that:

- Lifeline provides a discount of up to $9.25 or $5.25 per month depending on service tier or bundle. I will be responsible for the remaining balance after the Lifeline discount is applied. This includes any taxes and required fees that are applied to the full amount of the service.(Required)

- I am either a current Lifeline customer or my eligibility has been verified by the National Lifeline Verifier so that I qualify for the Lifeline.(Required)

- My household may obtain broadband service supported by the Lifeline from any participating provider of my choosing and I may transfer my Lifeline benefit to another provider at any time.(Required)

- I may only receive one Lifeline benefit per household, from one participating provider, and I certify that no other member of my household is receiving Lifeline.(Required)

- All official communications for Lifeline will be via electronic mail or text messaging and I consent to receive such communications from Gearheart Fiber, Inter Mountain Cable, Gearheart TV, Coalfields & Mikrotec CATV(Required)

- I agree that all information I provide on this form may be collected, used, shared, and retained for the purposes of applying for and/or receiving the Lifeline benefits.(Required)

- Any Benefit Qualifying Person (BQP) can only qualify for one household.(Required)

Signature Needed

Signature

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Lifeline Application Form

Subscriber Consent

GEARHEART LIFELINE PROGRAM QUALIFICATION FORM

By signing this form, I give my affirmative consent that I want to participate in the Affordable Connectivity Program through Gearheart Fiber, Inter Mountain Cable, Coalfields Telephone or Mikrotec CATV and that I understand and certify that:

Signature Needed

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