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Ⅷ :路習貪W路F混Ч‖贄総黒器冊累翻ミ冨:晰朧ソ黒鍵鵬ぜ胤T鰍

7鳳‖[‖FNen dl thOng‖ n dυ Oi dOy ThOng‖ n chLPO day dl h。IC COn thi6u c6 thalam cho dα n xin bi十 む ch6 hoac cham c● u xёtt NOn nop dOn naycang v●iban sao bと ng chiPng vさ lγ i l●c,lhl an sinh xa hoi ctto moing"il『 ong gic ho,va h6o don len ich khrd6,,dien,dien,hooiva n"c

l SO AnSnh XO H6 2, Ngdy sonh 3.Ngoy de don 4 Ph01+inhl()Nom()N●

5 HO clo ngu01de dOn 6 TOn clo nglPOi de don 7 Ch● 10+vi`十 十五十 8S6dien thoal‖ ёn lac

9, Dio chi dudng ph6 10S6con h6

14 DOy c6 pha‖O dio chittam ttha khong? O C6 □KhOng

15 Loa nh0 61()MO十 giO dnh()Nhiさu glo dnh

12 PhυOng 13 ANC1l Bげ u chanh

17 Nguふ n dun sυ ol

19.Tra十 1さn cho bOn

.l6, QuV vi c6 phii ld chrl nhd kh6ng? ( ) C6 ( ) Khong

ch6nh: ODi€n O Khid6tO Dtu O Ngudn kh6c .l8, Khoin dun sudi c6 g6m trongtiAn thu6 nhd kh6ng? OC6 O Khong

bdn sou ddy (d6nh dAu mOt (l) 6): r PEPCO n Woshington Gos o C&M Oil o Griffith/Stuort Oil o Hdng khoc-

20. 56 truong muc:

21, Tong s6 nguoi trong gio h0: 22T6ng lol十 ●c glo ho hong nom

□M6i hol十uan □Hong th6ngo Hdng tuAn □MOi nむ o十h6ng n Hdng ndm

23 Ngυむitrong glo ho S6SSN BI+On ta十 ? L《ッi十二pc

24o Ngげ ol十rong 91o h0 SO SSN Bittan ta十 ? L(ッ |十て,c

24b, Ngudi trong gio h0 SO SSN Tu6i Bitan十 a十? L《ソ|十二,c

TOn bOn b6n 十「じαng muC den(RAD(ReSden‖ 。I Ad Discount hoy Ciam Ci6 COu Trg Cio CtP)) T6n nguoi trong trii h6o don

TOn bOn b6n S6+Ⅳ αng muc khrd6+(RES(Residen‖ ol Essen‖ ol Senυ ices′ hoy Dich∨ u cho Cic CLPy) T6n ngudi trong trdi h6o don

27 DC WoferTOn b6n b6n 56 truong mr,lc nuoc (CAP (Customer Assistonce Progrom, hoy Chuong Tr'inh Tro Ginp Kh6ch Hdng)) T6n nguoi trong trii hoo don

X6c Nhan Don Xin Nhiem Kiam Ch●ng LOi TiPC:

28 T01+uyOn the hOlc khing dinh10+`十 ca thOng‖ n trong dα n xin nOy― cOng vd mOlthOng ttinl輛nh dO holcsё nOp d6 d5n ch● ng cho dcn― dёu

chan tthal,chFnh xOc va dな y do十rong chむ ng mΨc hiёu bi6t kha nong Vo X6c rn i6t nh`十 clo ban than Tol httu rら ng繭 nh c6ヤh6bi phat tiさnvO/holc+6ng giom u khoittnnh gion d6i ch● k,cOo 101+「 ёn don力 n nay chO phёp DDOE‖ OniaC Va b`十 c● bOn nOo can th16+dё kiem chレng

thOng ttn t6i dO cung c`p

29 TOl hi6u10前 nh sё nhan duoctthOng b6o n6u nguan qu,tro Cap nongし ong da h6t hOlc n6u don noy bi十むch6i

30 NoldOy+011y nhiem cho c6c hang† ienに h‖ 6+lo s6 trtFOng muC VO十 hOng ln ttilP十 rυ ong muc cむ o10し 十rong d6 g6m ca thong in chitra tr6′ nho vay

DDOEvO c6c+6 ch● c hanh dong nhon donh DDOEse dellPong dinh hieu qua cむ o dich vu dO DDOE cung c`p cho kh6ch hang

31 Ti6,:0:Nci dOy TO:_KHANG D!NH___PHI D!NH vieC dさ ng,d6DDOE cung c`p tthOng‖ nttrong h6 sc cOo loi cho cOc hang‖ enに h vo ETC

(E‖gible Telecommunico‖ ons Corner′ hOy HOng Vi5n ThOng Hop chuan)chi輌 muc dchX`ploa gi6 biё u v。 16p thitheo UDP(ChuCng Tnnh ciぅ mCI● Tlen tth)′ cho nh●ng cα qucIIn vё 16 ch● c kh6c mO 10i mu6n xin trg gi6p+Oi ch6nh′ vO u muC(fCh klさm ch● ng′ nghiOn cOu′ d6nh 9i6 v0

phan十にh

cho kiTOi hi6u ring minh phai trong trai h6o don tien fch, bAtkB don xin ndy c5 duqc ph6 duy0t hoy kh6ng.

t'lD〔 PARTMLNIOF llll

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一DσN X:NG:A NHAP CHtFCNG TRINH LIFELINE

□ 丁AI

VarrFN NCutt rPANC

XAC NHANlM′ ″薇 DαⅣ熙ONC rPttNc Mυ c

1,S6An Sinh XO HOI 2. Ngdy sonh 3 Ngoy de dσ n 4 Ph61+hhl()Nom()N●

5 H9clo ngυ Oi de dCn 6 TOn clo ngじoi de dCn 7 Chむ 16+v16+十五十 8 S6dien thoa‖ iOn laC

9D:o chidυ Ong ph6

14 Dio chigd h6o don

10S6cOn ho 1l Bピ u ch6nh 12,Phυ むng 13 ANC

15 DOy c6 pha‖ O dio chittam thOi khOng? □C6

16.Loai nh0 01()MO十 giO crnh()Nhiさu gio dnh

18.T6ng lσ l十●c gic ho hang nom:

o Kh6ng

t Z. t6ng s6 ngudi trong gio h0:

十uan □M51 hol十uan □ □M5nむo o Hdng ndm

Dich vu Lifeline ld quydn lEi li6n bong, vd n6u c6 V khoi trinh gion d6i trOn don xin ndy thi s6 bi phat tiAn, t6ng giom, x6o ten hoac vTnh vi6n khoi trir khdi chuongtrinh. Chi cho ph6p c6 mgt quyAn lqi Lifeline trong m6i gio n9 gdm nh0ng ngudi thudng tr0 d c[rng mQt dio chi vd ddng son s6 phAn lqi hic vd chi phi.

0y Bon Truyln Th6ng Li6n Bong ddi h6i qui vi phai cho bi6t th6ng tin phu trci thi moi ti6p tuc duqc dich vu Lifetine; nen xem ben du6i. N6u chlng cung cApth6ng tin dAy drl vd th6o d6ng thi se khong dugc gidm gio dich vu diin thoai hoac bi cop dich vu Lifetine.

Chl cr6i vhi nguoi cre don gto nHp Lifeline: Cht6u lheo hinh phgt v6,Oi khoi gion, qu, vt phili kf t t CI6 xdc nhQn ld:

'I : T6i hOi di ti6u chuAn vi c6 m0c lqi tr.?c gio hO d6p Ong diAu kiQn, hoAc t6i hQi Cti ti6u chuln vi dong duqc hudng quydn lqi sou ddy(d6nh d`ul`lca c6c muc十 htth hop) r TANF o SNAP (Phi6u Muo Thyc PhAm) o Medicoid □SSI □L HEAPo Trq CAp Gio Cu COng CQng crio Lien Bong (Doan 8) tr Chuong Trinh Qu6c Gio vA An Truo Tai Trudng (Chuong Trinh An Truo Mi6n Phi)rTheο drnh ngttα g′oたo′atガ′C′ c6nゎanわo/nh6m ngtt naο s6ng chυ ng∂ cttng mo′ d10 Ch′ 崎 d6ng scn"ρ わan 191)に しocわ′ρわ,

2:____Httn ta Ca 10‖うn moi ngtPoit「ong gic ho dё u chtPo dtPgc hu● ng b`十 c● dich Vu Llfeline nOo lむ Sofe‖ nk,TrocFone′ holc nhO Cung c`p dich vu dien十 hoaikhOc;

3:____TOiSe b60 cho ETC(Hang Viё n Thong Hgp Chuan)bi6† 十rong vong 30 ngay n6ul。 |十●c cOo而 nh khOng cёn ho dOI10u chuAn dυ oc Lfe‖ ne nOo′ holc ukhOng cOn hυ Ong quyё nloi↑ heo TANF′ SNAP(Phi`u Muo ThtPc Pham)′ Medicold′ SSI′ LIHEAP′ TrO Cap cio cψ cOng Cong C00 LiOn Bong(Doan 3).hoyChuong lnnh Qu6c clo vさ 八n Truo Tal Trじ ong(Chuα ng TnnhÅ n Truo Miё n PhD:

4:____TOiSe b60 cho ETC b6† trOng vOng 30 ngay n`u c6 ngυ ollЮng gio ho(kё Cう ↑o)dtFcC nhttu hon mo十 quyё n loi Life‖ ne′ chang han nhtFIむ Sofe‖ nk′TrocFone′ holc nha Cung cap dich vv dien thoalkhOc;

5:____TOiSe b60 cho ETC b`† †rOng vOng 30 ngOy n`u ttnh dOn ttOi dio chirn61

6:____N`u10i do chO bi6+dio chitam thOI十 n se†tP而nh kiё m ching diO Chinay m6i9o ngOy,

7:____TOi hiё u rang n6u cung c`p thong tin g饉 †「O hoy gicIIn d6i dё dtPcc diCh Vu Lre‖ ne十日se bilua† phop trむng phat vO面nh phalxoc nhanlai m6inё m十nmθ i‖ 6p tuc hlPOng dich vv Lre‖ ne,

81____T6ihiёu rang n6u khong x6c nhanlaitn se bix6o Юn vO ch`md● 十gllm gi6 dich Vu dien thOat

_Nё u vipham quyl`c・ m6igio ho chiduoC mo十 dich vu Lre‖ ne‖ th se bixoO len vO chuyen song dich vu dien thoalc6 gi6 biё u d6ng nh`t Lreine lo quyё n10ikhOng thё chuyё n nhtPOng;161 hlё u rang khOng thё chuy6n nhυαng dich Vu Lifelne cOo ban十 hon chO ngυ さlkhOc

■61:0:Nα i dOy TO:___KHANG D!NH___PHI D!NH vieC d6ng′ d6DDOE cung cap thong in十 rong hOsc cOo loicho cOc hOng† len tth vo ETC(E‖ gible

Telecommunlcoャ ions Cor‖er′ hoy Hong∨ iёn Thong Hgp Chuan)chiu muc(“ ch X`p loai g10 bttu vo li6p lhitheo uDP(Chυ αng Tnnh ciam clo Tien lch)′ chonhing cσ quon vO 16 ch● c khOc mO 10i mu6n xin† ro gi6p 10i ch6nh′ vO u muc dCh kiё m ching′ nghiOn c● u′ d6nh gi6 vO phOn lch

TOittuyOn† he(hOlc khang dinh)101`十 Catthong tin trong dcn xin nOy vO d● ‖eu da nop dё dan chψ ng Cho dαn dё u chonthal′ chhh x6c、O day do trong chむ ng

muc kha nong′ hiё u bOlvo xoc th t6t nh`十 cOo banthon Ch● k,CO。 +6itrOn dα n xin nOy cho phё p DDOE‖ On● c V6ib`十 c● bOn nOo can十 hi6+dё klё m chψng

lhOng ttin tOi dO cung c`p vO dё boo cho hOng tien Ch bi6t10 1oihoi dl lleu chuan

ChiP kiTOi hi6u rAng minh phdi trong lrei h6o don tien ich. batkB don xin ndy co duqc ph6 duyet hoy kh6ng,

0:Si RIC■DIPARIMEN「0,IHI

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