I agree, under penalty of perjury, to the following statements:
By checking this box you are consenting that all of the information you providing may be collected, used, shared, and retained for the purpose of applying for and/or receiving the Free Internet Program.
By checking this box you are consenting that all of the information you are providing on behalf of a qualifying dependent may be collected, used, shared, and retained for the purpose of applying for and/or receiving the Free Internet Program.
I understand I am only allowed to get one Lifeline benefit and one Emergency Broadband Benefit (if applicable) per household, not per person.
I understand that this limit is an FCC rule, and lying about my household on this government form can make me lose my Lifeline benefit or my Emergency Broadband Benefit and is against the law.
I agree that if I move I will give my service provider my new address within 30 days.
I understand that I have to tell my service provider within 30 days if I do not qualify for Lifeline anymore, including: Initial I, or the person in my household that qualifies, do not qualify through a government program or income anymore. 1. Either I or someone in my household gets more than one Lifeline benefit (including, more than one Lifeline broadband internet service, more than one Lifeline telephone service, or both Lifeline telephone and Lifeline broadband internet services).
I know that my household can only get one EBB benefit and, to the best of my knowledge, my household is not getting more than one EBB benefit.
I agree that my service provider can give the Lifeline Program administrator all of the information I am giving on this form. I understand that this information is meant to help run the Lifeline Program and that if I do not let them give it to the Administrator, I will not be able to get Lifeline benefits.
All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.
I know that willingly giving false or fraudulent information to get Lifeline Program benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program.
My service provider may have to check whether I still qualify at any time. If I need to recertify (renew) my Lifeline benefit, I understand that I have to respond by the deadline or I will be removed from the Lifeline Program and my Lifeline benefit will stop.
I understand that the free monthly internet is for only as long as the FCC program continues with the current funding.
Type your full legal name above.