Lifeline Benefit Consent

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First*

Last*

Account Number:*

DOB:

Phone:*

Last 4 of SSN:*

Street Address

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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

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:*