LifeLine Form

LIFELINE/LINK-UP PROGRAM

Self-Certification Form

Date: ______________

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)

□ Low Income Home Energy Assistance (LIHEAP)

□ Federal Public Housing/Section 8

**Note: Your case worker will need to verify your eligibility.

If your household income is at or below 135% of the poverty level ($27,877.50 or less for a family of 4), and you are not currently receiving benefits from one of the listed programs, you may be able to qualify for LifeLine/LinkUp by contacting the N.C. Public Utilities Commission at (919) 716-0059.

I certify, under penalty of perjury, that I am a current recipient of the above program(s) and will notify Aspire Telecom, Inc. when I am no longer participating in at least one of the above-designated programs. I authorize Aspire Telecom® 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 provide copies to Aspire Telecom to verify my participation and my eligibility for Lifeline/LinkUp.

___________________________________ _______________________

Applicant’s signature Date

Please fax and then mail this self-certification form to:

Aspire Telecom, Inc.

P. O. Box 2174

Asheville, NC 28802

Toll-free Fax: 800-792-2961 or 828-236-0418 Phone: 828-236-0406 or Toll-free: 888-227-7473.