I hereby opt-in to the Lifeline Benefit Program
I qualify for the program based on income-based or program-based eligibility requirements of the Lifeline Benefit Program. 
I acknowledge that the Lifeline benefit is a government assistance program for eligible consumers.  The non-transferable discount is limited to one Lifeline discount per household, and I further certify that no other member of my household is receiving a Lifeline benefit.  A household is defined, for the purposes of the Lifeline program, as any individual or group of individuals who live together at the same address and share income and expenses.

I acknowledge if I move to a new address, I will provide that new address to JCE Co-op within 30 days.

I consent to applying my Lifeline program benefit to the phone or broadband internet service I receive from JCE Co-op.

I consent to JCE Co-op disclosing and/or transmitting any information required to the program Administrator for my participation in the program including but not limited to my name, my dependent’s name, date of birth, last 4 digits of social security number, address, telephone number, type of service, start date of service, termination of service date, eligible program, and Independent Economic Household certification date.

I consent to JCE Co-op verifying my household’s broadband usage each month to enable JCE Co-op to claim reimbursement for my program benefit each month if applicable.

I acknowledge that if JCE Co-op has a reasonable basis to believe that I am no longer eligible to receive the Lifeline benefit, I will receive a notification of impending termination of my Lifeline benefit and will have 30 days following the date of such notice to demonstrate continued eligibility.

I acknowledge that I may obtain Lifeline-supported phone or broadband service from any participating provider of my choosing and that I can transfer the Lifeline Benefit to another provider at any time.

I acknowledge that if I cannot demonstrate eligibility, I will not be enrolled in the program and/or JCE Co-op is required to de-enroll me from the program.

I acknowledge that my participation in the Lifeline Program does not relieve my obligations to adhere to JCE Co-op’s posted rates, terms and conditions, or other rules and regulations or tariffs that govern the services I receive.

I acknowledge I may be required to re-certify continued eligibility for Lifeline at any time, and the failure to re-certify to continued eligibility will result in de-enrollment and the termination of Lifeline benefits pursuant to § 54.405(e)(4).

Lifeline is a federal benefit and that willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the program.

I certify that information contained on this form is true and correct to the best of my knowledge.  I also certify I have confirmed my eligibility for the Lifeline benefit through the National Verifier.