ITS Telecom

Lifeline/ Link-Up

Lifeline and link-Up Certification Form
Date of Application
Billing Name
Service Address
City
State
Zip Code
Social Security Number
Telephone Number
I hereby certify that I participate in the following public assistance program(s)
Medicaid
Food Stamps
Temporary Assistance to Needy Families (TANF)
Supplemental Security Income (SSI)
Federal Public Housing Assistance (Section 8)
Low-Income Home Energy Assistance (LIHEAP)

I authorize my local telephone company or its duly appointed representative to access any records required to verify these statements to confirm my continued participation in the above program(s). I authorize representatives of the above programs to discuss with and/or provide copies to my local telephone company, if requested by the company, to verify my participation in the above program(s) and my eligibility for Lifeline.