Lifeline Benefit Consent Lifeline Program718 S West St, PO Box 98 Green City, MO 63545 660-874-4111Consent to Apply Lifeline Benefit to NEMRORTransferring My Current Lifeline Benefit to NEMRACCOUNT INFORMATION Account Owner: First Last Account Number:DOB: MM slash DD slash YYYY Phone:Last 4 of SSN: Service Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Complete information exactly as entered into the National VerifierBenefit Qualifying Name: First Last DOB: MM slash DD slash YYYY Last 4 of SSN: Check the Appropriate Box BelowChoose One:(Required) 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. I am currently receiving the Lifeline Benefit from another provider and give my consent to transfer the Lifeline Benefit to service received from NEMR. PROGRAM DISCLOSURES:I acknowledge that NEMR has explained that I cannot receive more than one Lifeline benefit per household.Account Owner:Date: MM slash DD slash YYYY
