Information of Qualifying Person

Please provide the information of the individual who qualified for Lifeline as it was entered at the FCC’s Qualify for Lifeline website to determine eligibility. This may be different than United & Turtle Mountain Communications’ account holder.

Please read the following statements, initial by each certification, and sign below.

By signing this form, I acknowledge and give my affirmative consent that I want to participate in the Lifeline Program through United & Turtle Mountain Communications and that I understand and certify that:

Additional disclosures for transfers-in:

I give my affirmative consent to transfer my Lifeline benefit to United & Turtle Mountain Communications, and agree and certify that:

CONSENT TO PROVIDE LIFELINE SUBSCRIBER INFORMATION TO THE NATIONAL LIFELINE ACCOUNTABILITY DATABASE

The Federal Communications Commission has established the National Lifeline Accountability Database (NLAD) to detect and prevent consumers from receiving more than one discounted telephone service under the federal Lifeline program. Under federal law, United & Turtle Mountain Communications is required to check this database prior to signing up Lifeline subscribers and is also required to provide the following information regarding each new and existing Lifeline subscriber to the federal database’s administrator:

• The Lifeline subscriber’s full name;
• The Lifeline subscriber’s full residential Address;
• The Lifeline subscriber’s date of birth;
• The last four digits of the Lifeline subscriber’s Social Security number or Tribal Identification Number (if the subscriber is a Tribal member and does not have a Social Security number);
• The telephone number associated with the Lifeline service;
• The date on which the Lifeline service was initiated;
• The date on which the Lifeline service was terminated (if applicable);
• The amount of Lifeline service support being sought for the subscriber;
• The means through which the subscriber qualified for Lifeline service (income or program-based, Medicaid, SNAP, etc.)

The above information related to your Lifeline service is being provided by United & Turtle Mountain Communications to the National Lifeline Accountability Database to verify that you, as a Lifeline applicant and/or subscriber, are not receiving more than one Lifeline benefit, and to otherwise ensure proper administration of the Lifeline program. If the National Lifeline Accountability Database indicates you already receive a Lifeline benefit, United & Turtle Mountain Communications will be required to deny the benefit to your account.

I, the Lifeline applicant/subscriber, acknowledge that United & Turtle Mountain Communications will transmit to the administrator of the National Lifeline Accountability Database the above-referenced information about my Lifeline account and/or service for inclusion into the Database, and hereby consent to transmission of the information for purposes allowed by law relating to administration of the Lifeline program. I further understand that a failure to provide this consent to release my Lifeline account and/or service information to the federal administrator for inclusion in the National Lifeline Accountability Database will result in a denial of or de-enrollment from Lifeline service.