Section 757.EXHIBIT E Link Up/Lifeline Programs Certification Form

ELIGIBLE TELECOMMUNICATIONS CARRIERS LINK UP/LIFELINE PROGRAMS CERTIFICATION FORM

NAME

DATE ISSUED

/ /

ADDRESS

APARTMENT

CITY

ZIP CODE

COUNTY

AGE

SOCIAL SECURITY NO.

PUBLIC AID CASE NUMBER

Are you a participant as of this date of application in one of the programs listed below?

In which program(s) do you currently participate?

Food Stamps

Medicaid

Supplemental Security Income (SSI)

Federal Housing Assistance Program

Low-Income Home Energy Assistance Program (IHEAP)

National School Lunch Free Lunch Program

Temporary Assistance to Needy Families

Under penalty of perjury, I confirm that I participate in the above stated program(s). I will notify my provider of local exchange service in the event I cease to participate in the program(s). By my signature below, I give the Social Security Administration permission to inform my local exchange telephone company whether or not I am entitled to Supplemental Security Income benefits as of the date of this application.

SIGNED

DATE

(Source: Amended at 30 Ill. Reg. 18196, effective November 1, 2006)