Lifeline Transfer-In From

LIFELINE TRANSFER-IN FORM

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Time

Date(Required)

Account Number(Required)

Inter Mountain Cable, Coalfields Telephone and/or Mikrotec CATV Billing Account Number

Lifeline ID Number(Required)

Name(Required)

First Middle Last

Benefit Qualifying Person(Required)

First Last

Date of Birth(Required)

School Name

(If you qualify for Free School Lunch)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone Number(Required)

Cell Phone Number

I give my affirmative consent to transfer my Lifeline benefit to Gearheart Broadband (Gearheart Fiber, Inter Mountain Cable, Coalfields Telephone and Mikrotec CATV) and agree and certify that:

I understand my Lifeline benefit will be applied to my new service and will no longer be applied to service retained from the transfer-out provider.(Required)

I may be subject to the transfer-out provider’s undiscounted rates as a result of the transfer if I elect to maintain service from the transfer-out provider.(Required)

I am aware of the one Lifeline benefit transfer transaction per service month.(Required)

Signature(Required)

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LIFELINE TRANSFER-IN FORM

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