LIFELINE PROGRAM CONSENT FORM

This signed Lifeline Consent Form is required to enroll you in Kingdom Telephone Company's Lifeline program. The National Verifier, not Kingdom Telephone, determines your eligibility to receive Lifeline. Only persons who have been determined to be eligible by the National Verifier should complete this form. If you have not qualified for Lifeline through National Verifier, please visit https://lifelinesupport.org to apply or complete your paper application. The information you enter on this form must be the same as what you provided to National Verifier.

Account Information

Account Name

First

Middle

Last

Date of Birth

Last 4 of SSN

Contact Phone Number

Address

City

State/Province

Zip/Postal

National Verifier Information

Benefit Name

First

Last

Date of Birth

Last 4 of SSN

Check the Appropirate Box Below

I have applied and been approved through the National Verifier to receive the Lifeline Benefit and give my consent to apply the benefit to service received from Kingdom Telephone Company.

I am currently receiving the Lifeline Benefit from another provider and give my consent to transfer the Lifeline Benefit to service received from Kingdom Telephone Company.

Program Disclosure

I acknowledge that Kingdom Telephone Company has explained that I cannot receive more than one Lifeline benefit per household.

Signature

Clear

Date

Lifeline

LIFELINE PROGRAM CONSENT FORM

Account Information

National Verifier Information

Check the Appropirate Box Below

Program Disclosure

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