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MILLRY COMMUNICATIONS
LIFELINE and LINK-UP RATE ASSISTANCE CERTIFICATION
Assigned Telephone Number:______________________
Assigned Customer/Member Number:________________
(To be completed by Company employee)
ELIGIBILITY FOR LIFELINE AND/OR LINK-UP ASSISTANCE IN ALABAMA IS DEPENDENT UPON PARTICIPATION IN ONE OF THE FOLLOWING PROGRAMS:
1.
 I hereby certify that I, my dependent who lives in my household, or another resident of my household for whom I am financially responsible participate(s) in:
  ___ Medicaid
___ Foodstamps
___ Supplemental Security Income (SSI)
 ___ Section 8 Federal Public Housing Assistance (FPHA)
___ Low Income Home Energy Assistance Program (LIHEAP)
___ Temporary Assistance for Needy Families (TANF)
2. I also certify that:
(A)
My phone service is listed in my name.
  (B) The address listed is my primary residence, and is not a second home or business; and,
(C) If participation in at least one of the programs as listed in Section 1 ceases, or if any of the conditionslisted in this Section 2 change, I will promptly notify the Company that I am no longer eligible to receive Lifeline Assistance.
3.


 I authorize the Company to access any records necessary to verify these statements and to confirm continued participation in at least one of the above programs. I authorize representatives of the above programs to discuss with and/or provide copies of such records to the Company , if requested by the Company, to verify participation in at least
4.

 I wish to subscribe to (indicate by check mark):
Lifeline Assistance ___________ Link-up___________
5.


 I (we) certify, under penalty of perjury, that the above information is true. I have read the information on the Certification and understand that I must meet the above qualifications to receive assistance from either of these programs.
APPLICANT'S NAME:______________________________________________
APPLICANT'S ADDRESS:____________________________________________
APPLICANT'S SIGNATURE:__________________________________________
TELEPHONE NUMBER WHERE APPLICANT MAY BE REACHED OR RECEIVE MESSAGES:
_______________________________________________________________________
APPLICANT'S MEDICAID #:________________ SOCIAL SECURITY #:__________________
DATE:______________________________________
NAME and SOCIAL SECURITY NUMBER OF PARTICIPANT, IF DIFFERENT FROM APPLICANT:
PARTICIPANT'S NAME:____________________________________________________
PARTICIPANT'S MEDICAID #:_______________ SOCIAL SECURITY #:_________________