The Federal Lifeline Program is an FCC benefit program that provides eligible low-income households with a monthly service discount and a connected device discount. Each household is limited to one Lifeline benefit per month from one service provider.
By signing this authorization, you are requesting to enroll in the Lifeline benefit program through Medequip Mobile. Medequip Mobile will provide support for Lifeline services and enable you to use your Lifeline benefit.
Conditions:
- One Benefit Per Household:
- I acknowledge that I am only allowed to have one Lifeline Program-supported service. I confirm that my household is not already receiving a Lifeline-supported service.
- Enrollment Terms and Disclosures:
- I agree to the terms and conditions outlined in this document and understand that my enrollment in the Lifeline program is subject to verification of my eligibility.
- I understand that providing false or fraudulent information to receive Lifeline benefits is punishable by law.
- I authorize Medequip Mobile and its agents to share my enrollment information with the state and federal agencies responsible for the administration of the Lifeline program, as required by law.
- I understand that I may be required to recertify my eligibility for Lifeline at any time or upon request. Failure to provide recertification may result in termination of the Lifeline benefit.
- Household Eligibility:
- I certify that my household meets the income-based or program-based eligibility criteria for the Lifeline program.
- I understand that only one Lifeline service is allowed per household and that I will lose my Lifeline benefit if I or any member of my household violates the one-per-household rule.
- I agree to inform Medequip Mobile within 30 days if my household ceases to qualify for Lifeline benefits.
Prohibitions:
- I will not transfer my Lifeline benefit to another person.
- I will not claim more than one Lifeline benefit for myself or any other person.
By signing below, you certify under penalty of perjury that all statements herein are true and correct. Failure to comply with these statements may result in your de-enrollment from the Lifeline program.
You hereby acknowledge and certify the following regarding the Lifeline benefit enrollment:
- You have read and understand the disclosures provided in this document regarding Lifeline benefit enrollment.
- You acknowledge that this authorization is contingent upon your eligibility for Lifeline benefits.
- You understand that providing false information is punishable by law.
- You agree to transfer your Lifeline benefit to Medequip Mobile.
- You authorize Medequip Mobile to check eligibility in USAC at any time to confirm or update eligibility.
Signature:
By signing below, you confirm your agreement to the terms and conditions outlined above and authorize your enrollment in the Lifeline program.
