Professional Documents
Culture Documents
Section 1
This section must be completed by the applicant. The applicant and all resident members of the household
must reside at the service address for this telephone service. If the Electric Bill is in another person’s name
at the same address as the applicant, you should include the name from the Electric Bill.
Preferred Telephone Provider: Only one telephone number in each household is eligible for the LITE-UP
Texas discount. Assurance Wireless has been listed as your preferred telephone provider.
The application must be signed by the applicant.
Section 2
The application should list all income from all members of their household – Minimum of 2 month’s income
proof (see the application for more detail.)
Section 3
The applicant should indicate which of the qualified benefit programs apply to their household. You
must provide proof of participation for all benefit programs that apply.
Special notes:
If any member of your household living at the address of the applicant is enrolled in one of
these programs then you will be eligible for the Telephone discount.
The documentation provided must show that the applicant is enrolled in either Food Stamps
(SNAP) or Medicaid in order to be eligible for the Electric discount.
You may also FAX the signed application and required documentation to 1-877-204-6314
YOU MUST INCLUDE A COPY OF YOUR LATEST TELEPHONE AND ELECTRIC BILLS
The telephone listed above is my primary telephone number and service is provided by:
Assurance Wireless
Name of my telephone company
I understand that only one telephone number in my household is eligible for the LIT Texas discount, and I
authorize the discount to be provided by the telephone company listed above.
X
Applicant’s Signature
By signing this form, I state that the information I have provided in this application is true and correct. I understand
that the information provided is subject to audit and investigation by the Public Utility Commission of Texas.
X Date:
Applicant’s Signature
Your total household gross annual income from all sources cannot exceed these guidelines:
Number of persons in Household 1 2 3 4 5 6 7 8
Total Household annual income - Telephone $16,335 $22,065 $27,795 $33,525 $39,255 $44,985 $50,715 $56,445
Total Household annual income - Electric $13,613 $18,388 $23,163 $27,938 $32,713 $37,488 $42,263 $47,038
Frequency
Type of Income Dollar Amount (Monthly, Weekly, etc.)
Wages from Employment as shown on pay stub or W-2 Form
Social Security
Retirement Income
Alimony or Child Support
Unemployment or Worker’s Compensation
All Other Earnings
IF YOU ARE QUALIFYING USING YOUR TOTAL HOUSEHOLD INCOME YOU MUST PROVIDE PROOF OF HOUSEHOLD INCOME
WITH THIS APPLICATION (provide all documents that apply)
• Copy of most recent pay stub(s) from all employers covering the last two months (for all members of the household)
• Your most recently filed tax return (must be signed) or W-2 form
• A signed letter from each employer indicating the level of your wage
• Documentation of social security income
• Copy of an unemployment form with eligibility dates
• Copies of the two most recent unemployment checks
• Copy of the most recent bank statement showing direct deposit of income (for SSI, Social Security, annuity, pension)