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EBBP APPLICATION & CONSENT FORM Customer Name:Customer Address:Icoms Account #:Customer Phone and Email:CRITERIA 1 – LIFELINE FEDERAL GUIDELINES – Customers applying for EBBP using the Lifeline guidelines below: ____ I hereby certify that my annual household income is at or below 135% of the Federal Poverty Guidelines for a household of its size.I understand that a “household” may be a single individual; a household may also be a group of people who are living together at the same address who are contributing to and sharing in the household’s income and expenses. A household may include related and unrelated persons.I certify that there are presently _____ members in my household.I have provided a copy of the following documentation in support of my statements regarding the amount of my annual household income: ______________________________________________________________________. 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___Supplemental Nutrition Assistance Program (SNAP)___Supplemental Security Income (SSI)___Section 8 Federal Public Housing Assistance (FPHA)___Low Income Home Energy Assistance Program (LIHEAP) ___Temporary Assistance for Needy Families (TANF)___ Veterans Pension or Survivors Benefit___ Tribal Programs – and lives on federal Tribal lands___National School Lunch Program’s Free Lunch ProgramI have provided a copy of the following documentation in support of my statements regarding participation in one or more of the above-listed assistance programs: __________________________________________________________. CRITERIA 2 – NEW EBBP GUIDELINES – Customers applying for EBBP using the new guidelines below: ____ Approved for the free or reduced-price school breakfast/lunch program, including the USDA Community Eligibility Provision____ Experienced substantial documented loss of income since February 29, 2020 and the household had a total income in 2020 below $99,000 for single filers and $198,000 for joint filers____ Received Unemployment Benefits____ Experienced substantial loss of income since February 29, 2020 that is documented by layoff or furlough notice or similar document that is verifiable through NLAD____ Received a federal Pell Grant in the current award yearACCEPTABLE DOCUMENTS – customers must provide an electronic or mailed in copy of any of the following documents. Documents can be mailed in to any of our stores located in Lubbock, Amarillo, Abilene, Burkburnett, TX and Hammond, LA. Documents will be submitted to the National Verifier to determine qualification. CISCO secure email can be used to submit documents with personal identifiable information. Vexus Reps may contact Robin Davidson to obtain your CISCO secure email. Once reps have their own CISCO account, use CISCO secure email to obtain documents with personal identifiable information. Customer then uses CISCO to reply back with documents. 2019 and 2020 Income Tax Returns – proving substantial income loss.Current income statement from an employer or paycheck stub.Unemployment Benefit Statement – showing customer had to sign up for unemployment.Letter from school for reduced lunches – showing child was on free and/or reduced lunch program.Pell Grant award letter.Student Aid Report from College.Program Award Letters for:SNAP (food stamps)MedicaidSupplemental Social Security Income (SSI)Veterans Pension and Survivor BenefitFederal Public Housing AssistanceTribal ProgramEMERGENCY BROADBAND BENEFIT PROGRAM DISCLOSURESI understand that the Emergency Broadband Benefit Program (the Program) is a government program that reduces a customer’s broadband Internet access service bill;I understand that the Program is temporary;I understand that my broadband Internet access service will be subject to undiscounted rates and general terms and conditions at the end of the Program; I understand that at the end of the Program, my undiscounted rate, including taxes, fees and equipment rental charges, will be $_______________. I understand that I may obtain broadband Internet access service from any other broadband Internet access service provider that participates in the Program (Program Participant), andI understand that I may transfer my Emergency Broadband Benefit to another Program Participant at any time.I understand that I may be required to re-certify my continued eligibility for enrollment in the Program at any time. Failure to recertify my eligibility will result in termination of my Emergency Broadband Benefit. I understand that the personal information on this form will be provided to the Universal Service Administrative Company (USAC), which is responsible for administering the Program, and/or its agents for the purpose of verifying that I am eligible for enrollment in the Program, and I hereby consent to the release of that information to USAC. I understand that I will be denied an Emergency Broadband Benefit if I do not agree to the release of this information. AUTHORIZATION AND CONSENTI authorize the Company to receive my Emergency Broadband Benefit and apply it as a discount to my monthly invoice for broadband Internet access service.I authorize the Company to continue as my broadband Internet access service provider at the conclusion of the Program.I further authorize the Company or its duly appointed representative(s) to: 1) access any records contained in any governmental or commercial database to verify my statements herein; 2) confirm my eligibility and/or continued eligibility for the Program; 3) validate, confirm or update my address; and 4) authorize representatives of the listed programs to discuss with and/or provide copies of such records to the Company to verify my eligibility for enrollment in the Program. ______ INITIAL THAT YOU HAVE READ AND AGREE TO EACH OF THE STATEMENTS ABOVE. APPLICANT’S FULL NAME:_____________________________________________________________ APPLICANT’S PERMANENT ADDRESS:____________________________________________________APPLICANT’S BILLING ADDRESS (IF DIFFERENT): APPLICANT’S DATE OF BIRTH: _______________________________________________________APPLICANT’S SOCIAL SECURITY NUMBER (LAST 4 DIGITS): __________________________________I hereby certify, that the information in this Application and Consent is true and correct to the best of my knowledge and belief. I have read and understand the Disclosures and Authorizations and Consents contained in this Application and Consent. APPLICANT’S SIGNATURE: DATED: VEXUS INTERNAL USE:Vexus rep name:vexus rep email:application processed in nlad:ENTERED IN CONTROL LOG:SERVICES SOLD AND RATE:PACKAGE RATE AFTER PROGRAM ENDS:Please email completed application to: EBBPTeam@.If you have questions, please contact us at EBBPTeam@. ................
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