Lifeline Transfer Consent Form
The Federal Lifeline Program is an FCC benefit program limited to one monthly service discount and one connected device discount per household.
Per the household rule, only one Lifeline benefit is allowed per household, and the benefit cannot be shared among multiple service providers or transferred to another person.
Disclosures:
I confirm my Lifeline service was transferred from North American Local to another provider
without my knowledge or consent.
I understand that my Lifeline Program benefit will be applied to service from North American Local and will no longer be applied to service retained by the transfer-out provider.
I understand that I cannot have multiple Lifeline Program benefits with the same or different service providers.
Certification:
I hereby certify that:
I have read and understand the disclosures provided in this document regarding Lifeline
benefit transfer.- I give consent to transfer my Lifeline benefit to North American Local.
- I understand that my eligibility for Lifeline benefits is required for this authorization to
take effect.
Signature and Consent:
By signing below, I confirm that I have read and understood the information provided and agree to transfer my Lifeline Program benefit to North American Local.