Da Fone Company: Da Fone Company: Local Phone Services

Home Phone Application

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Service Type: *

Working Service?: *

Applicant's Current Number:

State Service Is Provided In: *

Do you receive Government Assistance? *

Lifeline Eligibility *

Applicant's First & Last Name: *

Last 4 Digits of Social Security Number: *

Applicant's Home Address: *

City: *

State: *

Zip Code: *

Applicant's Contact Number: *

Email Address: *

Authorization is required in order to enroll you in the Lifeline/Link-Up-America program in your state. This authorization is only for the purpose of verifying your participation in these programs and will not be used for any other purpose. Service requests will not be processed until this form has been received and verified by Company.

I certify, under penalty of perjury, that I am a current recipient of the above program(s) and will notify my local telephone company when I am no longer participating in any of the above-designated program(s). I give permission to the duly authorized official(s) administering the above programs to provide to the local telephone company my participation status in any of the above program(s). I give this permission on the condition that the information in this form and any information about my participation in the above programs provided by officials be maintained by the company as confidential customer account information.

I also certify that: (1) My telephone service is listed in my name. (2) I am not listed as a dependent on another person's tax return (unless over the age of 60). (3) The address listed is my primary residence, not a second home or business.

Please read and certify the following statement by checking the below box: *

I Agree I Disagree

( * Required Field )

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