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Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form!

The LITE-UP Texas Program can:


1. Provide a discount off your monthly telephone bill.
2. Provide a discount on your electric bill if you live in an area where you have a choice of electricity providers
(May through August 2011 bills)
3. Additional benefits for electric service include: Waiver of late payments and option to pay the security
deposit in two installments, if over $50.00.

Instructions to Complete the Application

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.

Mail the completed signed application and required documentation to:


Assurance Wireless
Attn: LITE-UP Texas!
420 Progress Drive
Mattoon, IL 61938

You may also FAX the signed application and required documentation to 1-877-204-6314

For Questions, Call Assurance Wireless toll-free at 1-888-898-4888 or www.assurancewireless.com!


SECTION 1 – Applicant Information
The person whose name is on the Telephone and Electric bills MUST fill out this section. The person in whose
name the utility bills appear must live at the service address.

Name of Telephone Customer:


(please print)
As it appears on your utility bill

Name of Electric Customer:


(please print)

Mailing Address: City: Zip Code:

Home Address: City: Zip Code:

Applicant Number: TX99999999999976 Social Security Number: - -


Email Address:

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

Declaration (please read carefully and sign)


The person in whose name the utility service is billed must complete and sign this section.

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

Before you Mail or Fax your Application


1. Make sure your name is printed in Section 1.
2. Make sure you write in the number of household members and complete the worksheets on page 2.
3. If qualifying by income: Make sure you list the income for ALL household members and provide ALL
of your income documentation.
4. If qualifying by program: Make sure you provide documentation to support participation in the
qualifying program.
5. Make sure you sign the application.
SECTION 2 – Income Enrollment Worksheet
HOUSEHOLD SIZE – Number of people living in your household: _____ (Include all adults and children residing at this address)

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)

SECTION 3 – Program Benefit Enrollment Worksheet


Telephone Discount Electric Discount
Enrollment by any member of your household Enrollment by the applicant/electric customer
in any of the programs listed below in either of the programs listed below
Food Stamps (SNAP) Food Stamps (SNAP)
Medicaid Medicaid
Supplemental Security Income-SSI
Health Benefit Coverage under Child Health Plan (CHIP)
Low-Income Energy Assistance Program - LIHEAP
Federal Public Housing Assistance
IF YOU ARE QUALIFYING BECAUSE OF ELIGIBILITY IN A QUALIFIED PROGRAM YOU MUST PROVIDE PROOF OF PROGRAM
PARTICIPATION WITH THIS APPLICATION

Eligible Resident of Tribal Lands (indicate which tribe): __________________________________________


Provide documentation of tribe affiliation and participation in at least one of the following: Bureau of Indian Affairs General
Assistance, Tribally-Administered Temporary Assistance for Needy Families, Head Start (only those meeting its income qualifying
standard), or the National School Lunch Program’s free lunch program.

Benefit Recipient – Telephone Discount Only


Please provide the name of the person in your household who is receiving one of the eligible benefits listed above.
Note: you must provide proof that this person participates in one of the eligible programs.

Name of Benefit Recipient: _______________________________________________________________________

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