NORTHEAST MISSOURI RURAL TELEPHONE CO.
718 S West St
Green City MO 63545
874-4111
Address: ______________________________________________
______________________________________________
Telephone: ______________________________________________
Link Up Missouri and Lifeline are Federal services which are available to qualifying low-income subscribers for single party residence service. Link Up Missouri provides a discount at the rate of 50 per cent or $30.00 whichever is less for the initial installation fee. Lifeline is a reduction in the monthly local service charges normally paid by the qualifying low-income subscriber. Eligible Lifeline subscribers will receive a total reduction of their basic local rate for residential one-party service of $8.25. Lifeline must be certified annually.
By my signature below, I certify, under penalty of perjury, that I am receiving benefit from (please check all that are applicable):
____ Medicaid
____ Food Stamps
____ Supplement Security Income (SSI)
____ Federal public housing assistance
____ Low Income Home Energy Assistance Program
____ Temporary Assistance for Needy Families program (TANF)
____ National School Lunch (NSL) program
____ Bureau of Indian Affairs General Assistance
____ Tribal NSL
____ Tribal Head Start
____ Annual income is at or below 135% of the Federal Poverty Guidelines (must be accompanied by supporting documentation)
My signature also certifies that the premises at which the residence service is requested is my principal place of residence and only has one telephone line serving the premises. I understand that I must notify Northeast Missouri Rural Telephone Co. if I no longer participate in the program(s) checked above. Northeast Missouri Rural Telephone Co. has my permission to contact the program(s) listed above to verify my active participation in the program.
____________________________________ _____________________
Signature Date