Lifeline Consent Form

Full Name *

Address *

Phone Number *

Birthday *

Last 4 digits of SSN *

National Verifier Application ID *

Are you eligible for benefit through a qualifying person? *

Yes
No

Qualifying Dependent Full Name *

Qualifying Dependent Birthday *

Qualifying Dependent Last 4 Digits of SSN *

Please read and initial each statement to confirm you have read and understand the disclosures related to applying your Lifeline benefit to your Wheat State Technologies account.

I am a Wheat State Technologies customer and am enrolled in the Federal Communications Lifeline Program. *

Yes
No

I agree that Wheat State Technologies can transmit my information to National Lifeline Accountability Database (NLAD). *

I have read and agree to the Terms and Conditions.

PLEASE SIGN BELOW: I have read the Broadband Internet agreement carefully, fully understand its contents, and voluntarily agree to its terms. *

Date *