New Customer Registration Form

Tribal Resources for Universal Service & Technology (T.R.U.S.T) Application
Applicant Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Are you currently residing on Spokane Tribal Land?*
Date of Birth*

MonthDayYear
Date
Household size*
Total Annual Household Income:
Eligibility (check one or more)*

Household income is at or below 200% of Federal Poverty GuidelinesSNAP (Supplemental Nutrition Assistance Program)MedicaidSSI (Supplemental Security Income)Veterans Pension/Survivors BenefitsFederal Public Housing AssistanceBureau of Indian Affairs (BIA) General AssistanceTribal TANFFood Distribution Program on Indian Reservations (FDPIR)Tribal Head Start (income-based)Federal Pell Grant (current award year)Free/Reduced-Price School Lunch or Breakfast Program
Proof of eligibility: *

Can be pay stub or tax return
Cancelof
Proof of eligibility attached?*

YesNo
Current internet provider:
Account number (if applicable):
Monthly Internet Cost:
Requested Subsidy:*
I certify that the information provided is true and correct.
I understand that this subsidy must be recertified annually to remain active. I understand I must submit my internet bills monthly, and if 30 days or more pass without submitting paperwork, Sp'q'n'i? Broadband Services reserves the right to offer the subsidy to the next qualified applicant. I agree to notify the Tribe of any changes in income, household size, or eligibility status. I also acknowledge that if eligibility status is not met, Spqni reserves the right to require repayment of the funds provided.
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Tribal Resources for Universal Service & Technology (T.R.U.S.T) Application