Lifeline Self Certification Form

TelAlaska customers currently enrolled in our Lifeline program may use the form below to self certify their continued eligibility. Federal regulations require that TelAlaska audit all Lifeline accounts every year to assure that our customers continue to meet eligibility requirements. The form below is for current Lifeline customers only. If you are not currently enrolled in Lifeline and wish to apply, you must compete this form and return it to TelAlaska with the required documentation.
If you have any questions regarding eligibility or completion of the form below, please contact TelAlaska at 1-800-478-3127 and we will be happy to assist you.       

Subscriber Name
Date of Birth
Last 4 Digits of Social Security Number
Mailing Address including City, State and Zip
Residential Address including City, State and Zip
Is your residential address temporary or permanent?    Temporary
Telephone Number
Are you or anyone else in your household currently receiving any low-income assistance from any other local or wireless telephone provider?
Please check this box if you are no longer eligible for Lifeline benefits. At the bottom of the form where it asks for your initials, please enter n/a.
Which one of the following Qualifying Public Assistance Programs are you currently enrolled in?
I acknowledge and certify under penalty of perjury that (1) I have read the information in this application; (2) the information contained in this application is true and correct; (3) I understand that I must meet the above qualifications to receive Lifeline assistance; (4) I agree to provide documentation of my eligibility when required to do so. (5) I understand that Lifeline is available for only one line per household and a household is defined as any individual or group of individuals who live together at the same address and share income and expenses; (6) to the best of my knowledge no one in my household is receiving a Lifeline-supported service from any other provider; and (7) I understand that Lifeline is a government assistance program and violation of the one-per-household requirement could result in de-enrollment from the program and potential prosecution by the U.S. government. Additionally, I understand that Lifeline support is only available for a single telephone line at my principal residence. (8) I understand that all information on this form is required for certification and will be electronically submitted to the National Lifeline Accountability Database. By participating in this government program, I agree to allow my personal information to be added to the national database. I understand failure to comply will deny me the Lifeline benefit. I agree to notify TelAlaska within thirty (30) calendar days if I no longer participate in the program(s) identified above. I agree to provide TelAlaska with a new address within thirty (30) calendar days of a future move. I further consent to the release of the information on this application (including financial information) pursuant to the administration of this program. I understand Lifeline is a nontransferable benefit and I may not transfer my service to another individual. I understand that I may be required to re-certify my continued eligibility for Lifeline at any time and failure to do so will result in the termination of my Lifeline benefits.

I acknowledge under penalty of perjury that failure to comply with the Lifeline regulations will result in termination of my Lifeline benefits (please enter your initials).
Digital Signature of Applicant (please enter your first and last name)
Email address
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