ID AUTHENTICATION FORM RESPONSE DATE: 10/7/2015

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September 17, 2015
ID AUTHENTICATION FORM
RESPONSE DATE: 10/7/2015
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Re: Identity authentication for California LifeLine Program (California LifeLine) for 999-999-9999
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The California LifeLine Administrator was unable to authenticate your identity on your recent California LifeLine application. In
order to be considered for the California LifeLine Program, you must complete and return this form along with a COPY of your
identification documentation. Some acceptable forms of identification documentation include: U.S. Driver License, Passport,
Certificate of U.S. Citizenship, Certificate of Naturalization or Citizenship, Permanent Resident Card, Permanent Resident Alien
Card, and U.S. government, military, state, or Tribal-issued ID, which includes date of birth and/or Social Security Number
and/or Tribal ID. For a complete list of acceptable forms of identification documentation, visit our website at
www.californialifeline.com or call (877) 858-7463.
IA1525800013
We must receive this form and your documents by 10/7/2015
or your application will be denied.
SIGN AND PRINT YOUR NAME - By signing below in compliance with federal and state government rules, I certify, under penalty of perjury,
that giving false or fraudulent information is punishable by law, that my household is qualified for the discounts, that my household will not
be getting more than one discount, that the service address is my principal residence, that I am not claimed as a dependent on another
person’s tax return, that I understand the notification rules, that I must renew my discounts annually, that if I do not renew I will lose the
discounts, and that the information in this form is true and correct. I agree to inform my phone company or the California LifeLine
Administrator within 30 days if I change my service address or billing address, if I no longer qualify for the California LifeLine discounts, or
if my household is getting more than one discount. I understand and agree that I will be penalized if I do not follow these notification rules. I
acknowledge and give my consent for the California LifeLine Administrator to share my information in this form to the Universal Service
Administrative Company and/or its agents. Legal Guardians or people with Power of Attorney are allowed to sign this form.
X
Applicant’s Signature (REQUIRED)
Today’s Date:
Fill in this bubble if signed by a Legal Guardian or a person with Power of Attorney.
Month
Day
Applicant’s First and Last Name (REQUIRED):
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