Lifeline Consent LIFELINE ASSISTANCE PROGRAM Confirm Your Lifeline Enrollment Complete the form below to give your consent to receive Lifeline-supported service through Allband. Lifeline Consent Form Step 1 of 2 50% All fields marked with * are required. Please enter the exact information you submitted on your application at www.lifelinesupport.org. Any differences (such as nicknames, titles, misspellings, etc.) may cause your application to be rejected.Subscriber's First & Last Name(Required) First Last PhoneEmail Address(Required) Street Address Apt/Unit # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information of Qualifying PersonPlease provide the information of the individual that qualified for the Lifeline Program as it was entered at the FCC’s Qualify for Lifeline website to determine eligibility. This may be different than the account holder with Allband.Lifeline Application ID(Required)What is an application ID? Eligible consumers receive an application ID after completing an approved Lifeline application. You can complete an application at www.lifelinesupport.org, or contact Lifeline Support at (800) 234-9473 or LifelineSupport@usac.org.Full Name(Required) First Last Date of Birth(Required) Contact Phone Number(Required)Email(Required) Please choose the option that applies to you(Required) I am enrolling; I do not have a Lifeline benefit with another provider. I am transferring my Lifeline benefit to Allband from another carrier. Lifeline Consent for Enrollment(Required) By signing this form, I acknowledge and give my affirmative consent that I want to participate in the Lifeline Program through ALLBAND and that I understand and certify that:1. The Lifeline Program is a government program that reduces the customer's voice and/or broadband internet access service bill. 2. I may obtain Lifeline-supported voice and/or broadband service from any participating provider of my choosing. 3. I may apply the Lifeline benefit to any voice and/or broadband service offering of the participating provider at the same terms available to households that are not eligible for Lifeline-supported service. 4. Allband may disconnect my Lifeline-supported service after 90 consecutive days of non-payment. 5. I will be subject to Allband’s undiscounted rates and general terms and conditions if the program ends, if I transfer my benefit to another service provider but continue to receive service from Allband, or upon de-enrollment from the Lifeline Program. 6. I may file a complaint against any service provider via the Commission's Consumer Complaint Center. 7. Lifeline provides a discount of up to a $9.25 per month toward broadband or bundled service (broadband and voice) for eligible households, and $5.25 for voice only. 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. 8. 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 a benefit under the Lifeline. 9. Official communications for Lifeline may also be via email and I consent to receive such communications from Allband. 10. I agree that all information I provide on this form and any service enrollment form may be collected, used, shared, and retained for the purposes of applying for and/or receiving the Lifeline benefit. 11. I understand that I have to tell my service provider within 30 days if I no longer qualify for Lifeline. 12. My service provider may have to check whether I still qualify at any time. If I need to recertify (renew) my Lifeline benefit, I understand that I have to respond by the deadline or I will be removed from Lifeline and my Lifeline benefit will stop. 13. All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.Electronic Signature (Type Full Legal Name):(Required)Typing your name in this field will represent your signature.Date(Required)
