LIFELINE TRANSFER 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? *

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

I acknowledge that my Lifeline Program benefit will be transferred to Wheat State Technologies. *

I understand that my Lifeline Program benefit will be applied to service from Wheat State Technologies and will no longer be applied to service retained by my previous provider. *

I understand, as a result of transferring my Lifeline Program benefit to Wheat State Technologies, I may be subject to my previous provider’s undiscounted rates if I choose to retain service from that provider. *

I understand that I cannot have multiple Lifeline Program benefits with the same or different service providers. *

I acknowledge that I have received the disclosures related to my request to transfer my Lifeline Program benefit. I understand these disclosures and I consent to the transfer of my Lifeline benefit to Wheat State Technologies.

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

Date *