Lifeline Benefit Consent

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Account Number:*

DOB:*

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Last 4 of SSN:*

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Benefit Qualifying Name:

First Last

DOB:

Last 4 of SSN:

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I've applied and been approved through the National Verifier to receive the Lifeline Benefit and give my consent to apply the benefit to service received from NEMR. 718 S West St, PO Box 98 Green City, MO 63545

I am currently receiving the Lifeline Benefit from another provider and give my consent to transfer the Lifeline Benefit to service received from NEMR. 718 S West St, PO Box 98 Green City, MO 63545. I understand that if I am currently receiving Lifeline benefits through another provider, those benefits will end with my previous provider when the transfer to NEMR is complete, and NEMR will then become my new Lifeline benefit provider.

PROGRAM DISCLOSURES:

By signing below I acknowledge that NEMR has explained that I cannot receive more than one Lifeline benefit per household.

Account Owner:*

Date:*