Lifeline Form

The National Verifier, not HES/energynet, determines your eligibility to receive Lifeline benefits. If you do not currently receive the Lifeline discount through the National Verifier, please visit www.affordableconnectivity.gov to apply. Only persons who have been determined to be eligible for Lifeline by the National Verifier should complete the Enrollment Form below.

For information about the Lifeline Program, please visit Lifeline Information Page

This signed Lifeline Enrollment Form is required to enroll you in HES/energynet’s Lifeline Program. The information you enter on this Enrollment Form must be exactly the same as what you provided the National Verifier to receive eligibility approval, which expires after 45 days. Submitting this form does not guarantee an immediate Lifeline discount with HES/energynet.

Lifeline Enrollment Form

Verification*
- By checking this box, I verify that I have read the above paragraphs.
National Verifier Application ID*
Name*
First Middle Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Last 4 digits of SSN*
Phone number listed on your HES/energynet account
HES/energynet Account Number (If a current customer)
Email Address*
Enter Email Confirm Email
RESIDENTIAL ADDRESS
Must be a street address (not a P.O. Box) and your principle residence
Street Address (911 Address)*
Street Address Address Line 2 City State ZIP Code
Mailing Address*
Street Address Address Line 2 City State ZIP Code
QUALIFICATIONS THROUGH DEPENDENT
Complete if you qualified in the National Verifier through a child or dependent in your household.
Name of Dependent
First Middle Last
Dependent's Date of Birth
Date Format: MM slash DD slash YYYY
Dependent's Last 4 Digits of Social Security Number
BENEFIT TRANSFER REQUEST (If applicable) By transferring my Lifeline support to HES/energynet, I understand that the Lifeline benefits will be applied to my HES/energynet Lifeline supported broadband and will no longer be applied to any services that I may keep with my prior provider. My household may be subject to my prior provider’s undiscounted rates as a result of the transfer for any services that I may maintain with that prior provider. My household is limited to one Lifeline transfer per month with limited exceptions to reverse an improper transfer or address situations impacting my household’s receipt of Lifeline supported service from a particular provider. I currently receive Lifeline benefits from another carrier, and I request that HES/energynet submit a Benefit Transfer on my behalf on the date below.
- I agree
CERTIFICATIONS
I authorize government agencies and their authorized representatives to discuss with, receive from and provide information to HES/energynet that is relevant to my eligibility to receive Lifeline benefits from HES/energynet. I consent and give permission for HES/energynet to transmit any of my personal information disclosed on this Enrollment Form to verify my eligibility with the Universal Service Administrative Company.*
- I agree
LIFELINE NOTICES AND DISCLOSURES
By signing this form, I give my affirmative consent that I want to participate in the Lifeline with HES/energynet and that I understand the following terms apply: I understand that the Lifeline Program can offer up to $12.75 with qualifying voice and internet service or $9.25 for broadband only. Unless otherwise stated herein, HES/energynet broadband services are subject to the HES/energynet Terms of Service found here. * My broadband service will be subject to HES/energynet's undiscounted rates and general terms and conditions if the program ends, if I transfer my benefit to another provider but continue to receive service from HES/energynet, or upon de-enrollment from the Lifeline Program. * HES/energynet may disconnect my Lifeline broadband service after 90 consecutive days of non-payment. Other services may be disconnected for non-payment according to HES/energynet’s normal processes. * Information I provide to HES/energynet may be collected, used, shared, and retained for the purposes of compliance with the Lifeline Program. * My household may file a complaint against its provider via the Commission’s Consumer Complaint Center at (877) 384-2575.
- I agree
APPLICANT SIGNATURE
By my electronic signature below, I certify that the information provided above is true and correct, and agree to the above Certifications. I further certify that I have read and understand the above Notices and Disclosures of this Enrollment Form.
Name*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY
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Lifeline Enrollment Form

RESIDENTIAL ADDRESS

QUALIFICATIONS THROUGH DEPENDENT

CERTIFICATIONS

LIFELINE NOTICES AND DISCLOSURES

APPLICANT SIGNATURE