ATTACHMENT G IMPORTANT NEWS FROM CENTURYLINK … · CenturyLink will provide the block, where feasible, at no charge to you. Telecommunications Relay Service . Dial 7-1-1 or Special

IMPORTANT NEWS FROM CENTURYLINK ABOUT YOUR PHONE SERVICE

Federal Universal Service Fund Changes – The Federal Universal Service Fund (USF) rate is reviewed on a

quarterly basis by the Federal Communications Commission (FCC). Consequently, you may see changes on your

bills in January, April, July and/or October. CenturyLink will apply rate changes on all applicable CenturyLink

charges, such as those for the local line, private line interstate, long-distance interstate and international service. The

Federal USF rate and charge are clearly identified on your bill. The effective rate can be found on

http://www.fcc.gov/encyclopedia/contribution-factor-quarterly-filings-universal-service-fund-usf-management-

support.

Federal Access Charge Changes - The annual adjustments of a federally approved telephone Subscriber Line

Charge and Access Recovery Charge took effect July 1, 2016. These charges cover part of the cost for providing

access to and maintenance of your local network. The effective rates can be found on your bill.

Your Rights Regarding Pay-Per-Call Information-Delivery Services - CenturyLink wants to be sure you are

informed of your legal rights related to pay-per-call information-delivery services. These are services you generally

access through dialing prefixes like “900” or “700” and that charge by the call or by the minute. Pay-per-call

services can include recorded telephone messages, interactive programs or other information services. CenturyLink

does not provide interstate pay-per-call services. But we do bill customers in our local service region on behalf of

many third-party companies, including interexchange long-distance carriers and billing aggregators. A number of

these companies, in turn, bill on behalf of pay-per-call service providers. You have specific rights and

responsibilities regarding pay-per-call charges that may appear on any of these various companies’ bill pages within

your CenturyLink bill. We are providing this notice in order to explain those rights as described in the federal

Telephone Disclosure and Dispute Resolution Act (TDDRA).

To Report a Billing Error - If you believe you have been billed in error for any pay-per-call services, call the toll-

free number listed on the bill page where the pay-per-call charge appears no later than 60 days after you receive the

bill containing the charges; or 60 days after the goods you ordered were delivered or should have been delivered,

whichever is later. When you call, be prepared to provide the following information:

• Your name and telephone number

• The date the disputed charges first appeared on your bill

• The amount of the disputed charges

• A brief explanation of why you believe you were billed in error

If you contact CenturyLink - either directly or because CenturyLink is acting as the first point-of-contact for a pay-

per-call billing entity - about a disputed charge, CenturyLink will credit your bill for the disputed amount and refer

the matter and the charges back to the billing entity. That billing entity, or the pay-per-call service provider, may

elect to pursue further action, so it is always good to follow-up with the entity billing the charges on behalf of the

pay-per call provider to assure full resolution of your matter.

Response From the Billing Company - In the event you contact the company whose name appears on the bill page

where the pay-per-call charge appears, in a timely manner, they must acknowledge your claim in writing within 40

days if they haven’t resolved your claim within that time. This company must also acknowledge that you are not

required to pay the disputed charge pending resolution of their investigation. You must still pay the nondisputed

portion of your bill; failure to pay may result in your access to pay-per-call services being involuntarily blocked

and/or collections activity against you. If the disputed amount has already been sent to collections, the collection

activity will be suspended. This same company must investigate, within 90 days of your initial complaint, whether

or not the disputed charges are valid. If there was a billing error, the billing company will let you know and will

adjust the charges as appropriate. If the charges have been referred to collections, the collections activity will stop. If

the billing company determines the charges were not billed in error, you will receive a written explanation detailing

how that conclusion was reached, how much you owe, and the date by which you must pay it. Failure to pay could

lead to collection activity. If you continue to dispute the charges, the billing company should not report you as

delinquent without also reporting that you continue to dispute the charges.

Compliance - Any long-distance carrier or billing aggregator acting as a billing agent for a pay-per-call service

provider that does not comply with the federal rules may not collect the first $50 of any disputed pay-per-call

transaction - regardless of whether or not the disputed charges are discovered to be correct.

ATTACHMENT G

http://www.fcc.gov/encyclopedia/contribution-factor-quarterly-filings-universal-service-fund-usf-management-support

http://www.fcc.gov/encyclopedia/contribution-factor-quarterly-filings-universal-service-fund-usf-management-support

Additional Customer Rights - You have a right not to be billed for pay-per call services that do not comply with

federal laws and regulations. Your local telephone service cannot be disconnected if you do not pay for pay-per-call

services. You may request a block to prevent access to pay-per-call services from your phone line.

CenturyLink will provide the block, where feasible, at no charge to you.

Telecommunications Relay Service

Dial 7-1-1 or Special Toll Free Numbers Listed in Your Telephone Directory

Telecommunications Relay Service is a free telephone service that allows persons with hearing or speech disabilities

to place and receive telephone calls using standard telephone equipment or telephone equipment designed for

individuals with disabilities. To use Relay dial one of the toll free numbers listed in your telephone directory, or

simply dial 7-1-1. A specially trained Communications Assistant (CA) will answer your call and relay the telephone

conversation between you and the party you are calling. All call information and conversations are confidential.

Relay service is available 24 hours per day, 365 days a year. Long distance calls placed for you can be billed to your

existing long-distance service calling plan, collect, or with the use of a pre-paid calling card, carrier calling card, or

third-party billing.

Types of TRS Calls

Computer (ASCII): users can access Relay Service by setting the communications software to the following

protocols: speeds ranging from 300 to 2400 baud: 8 Bits, No Parity; 1 Stop Bit; Full Duplex. For speeds at or below

300 baud, follow the above using Half Duplex.

Hearing-Carry-Over (HCO): HCO allows hearing individuals with very limited or no speech capability to type his

or her conversation for the Communications Assistant to read aloud to the hearing person. The HCO user hears the

other party’s response. HCO requires a specially designed telephone.

Internet Protocal (IP) Relay: Connect to the relay using your computer or other web device. The Communications

Assistant handles the call the same as a traditional relay call - “voicing” or reading everything you type to the other

party - and typing everything the other party says for you to read on your screen.

Spanish Relay: Spanish speaking persons with a hearing or speech disability are able to make relay calls. This is

not a translation service – both parties must speak Spanish, and at least one party must have a hearing or speech

disability.

Speech-to-Speech (STS): STS allows a person who has difficulty speaking or being understood on the phone to

communicate using his or her own voice or voice synthesizer. The Communications Assistant revoices the words of

the person with the speech disability so the person on the call can understand them. No special telephone is required.

Text Telephone (TTY): Allows anyone who is deaf, hard of hearing or speech disabled to use a TTY to

communicate with anyone using a standard telephone.

Video Relay Service (VRS): Allows natural telephone communication between Sign Language and standard

telephone users. This service requires high-speed internet service such as DSL, cable modem, or mobile broadband

modem.

Voice-Carry-Over: VCO enables people who have difficulty hearing on the phone to voice their conversations

directly to the hearing person. The CA then types the hearing person’s response to the VCO user. (Requires a special

telephone with text display.)

Voice/Standard Telephone: A hearing person may use a standard telephone to place a relay call and easily

converse with a person who is deaf, hard of hearing or speech disabled.

Voice Over Internet Protocal (VOIP): VoIP customers can access the

Telecommunications Relay Service (TRS) by dialing 7-1-1 or using the toll-free number listed in your telephone

directory.

Captioned Telephone Relay

CapTel uses a telephone with a text display screen to allow a person who is hard of hearing to see word-for-word

captions of what the other party on the call is saying, while also listening to what is being said using their residual

hearing (much like TV captioning). The CapTel user speaks directly to the other person on the call, and the CA uses

voice recognition technology to repeat what the other party says, which is then transmitted as text to the user’s

specialized CapTel phone.

TTY Users and Emergency Assistance (“9-1-1”)

TTY callers should dial 9-1-1 directly. All 9-1-1 centers are equipped to handle TTY calls. Using Relay for 9-1-1

may result in a delay to getting your urgent message through. For more information about TRS, please go to the

following URL: http://www.centurylink.com/Pages/AboutUs/Community/Disabled

ATTACHMENT G

Monitoring and Recording of Calls with CenturyLink Business Offices and

Other CenturyLink Representatives

Please remember, when you call CenturyLink for sales, service or repair issues, CenturyLink may monitor or record

those calls for quality assurance or training purposes. Additionally, when a CenturyLink customer service

representative or repair technician calls you, those calls too may be monitored or recorded for the same purpose.

Please inform all members of your household or business who may be in contact with CenturyLink of this

information.

High Cost Fund (Applicable to Colorado Customers Only) - You may have noticed a charge on your telephone

bill for the Colorado Universal Service Fund. This charge is required by the Colorado Public Utilities Commission

(PUC) to pay for the Colorado Universal Service Fund established by state law.

What is the Colorado Universal Service Fund? It is a fund to ensure that basic telephone service is affordable in

Colorado, and to support the building of broadband networks in unserved areas. Money from the fund is: (1) used to

support basic local phone service in non-competitive areas where costs to provide service are high, allowing local

phone rates to remain reasonably comparable across the state, and (2) assigned to a state broadband board and then

used to fund the building of broadband networks in unserved areas in Colorado.

What services is this charge applied to and who pays it? This charge is assessed as a percentage of your in-state

telecommunications services for local, wireless, paging, in-state long distance and optional services. The charge is

not applied to interstate services. All telecommunications customers in Colorado pay this monthly charge.

What is the monthly charge?

The monthly charge is currently set at 2.6 percent. The PUC may adjust the charge over time depending on how

much money is needed for the fund and to make sure that customers do not pay more than is necessary.

Who do I call if I have questions about this charge? For more information, contact your telecommunications

provider.

Slamming - Have you ever been slammed? Would you know if you have? Slamming is when one telephone

company changes a customer’s telephone service - usually long distance service - to another telephone company

without that customer’s permission. CenturyLink is here to offer some helpful tips on how to avoid being a victim of

slamming. Initially, you should call your local telephone company and request a “PC FREEZE” (Preferred Carrier),

which will prohibit future changes to your carrier selection until further notice from you. If you receive a call from a

telemarketer asking you to change your long distance service and you are happy with your current service, just say

that you are not interested and hang up. Don’t verify your name, your spouse’s name, or your address and never give

out your Social Security number. Always carefully read the fine print on everything, including any checks, offers for

calling cards, sweepstakes or drawings. If you are slammed, notify your local company to reconnect you to your

preferred long distance company at no charge. If the rates charged are higher than your normal rates, you may be

entitled to a refund.

Telephone Assistance - CenturyLink participates in a government benefit program (Lifeline) to make residential

telephone or broadband service more affordable to eligible low-income individuals and families. Eligible customers

are those that meet eligibility standards as defined by the FCC and state commissions. Residents who live on

federally recognized Tribal Lands may qualify for additional Tribal benefits if they participate in certain additional

federal eligibility programs. The Lifeline discount is available for only one telephone or broadband service per

household, and can be on either wireline or wireless service. Broadband speeds must be 10 Mbps download and 1

Mbps upload or faster to qualify. A household is defined for the purposes of the Lifeline program as any individual

or group of individuals who live together at the same address and share income and expenses. Lifeline service is not

transferable, and only eligible consumers may enroll in the program. Consumers who willfully make false

statements in order to obtain Lifeline telephone service can be punished by fine or imprisonment and can be barred

from the program. If you live in a CenturyLink service area, please call 1-855-954-6546 or visit

centurylink.com/lifeline with questions or to request an application for the Lifeline program.

Annual Customer Do-Not-Call Notification - The federal government established a national Do-Not-Call

Registry where consumers can register their residential telephone number(s) (including wireless) for free and it will

remain on the national Do-Not-Call Registry until you remove or discontinue it. Consumers can register their

ATTACHMENT G

numbers from the phone number they wish to register by telephone at 1 888-382-1222 or through the Internet at

www.donotcall.gov. TTY users should call 1-866-290-4236.

8-1-1 Call Before You Dig - Digging into underground telephone, electric, gas or water lines can disrupt service to

your area or could cause serious injury and you could be charged substantial fines. For peace of mind, please call 8-

1-1 at least two days before digging up your property. This is a free service.

Privacy - CenturyLink is committed to maintaining our customers' privacy. Like most companies, we collect

information about our customers and use it to provide our services. We also share it as needed to meet our business

goals or fulfill our legal obligations. We protect the information we have about our customers, and we require those

we share it with to protect it too. Our Privacy Policy describes the information we collect, how we use and share it,

the choices you have about our use and sharing, and the steps we take to protect it. You can find our Privacy Policy

here http://www.CenturyLink.com/privacy/ or, if you are unable to access the Internet, write us at CenturyLink

Privacy Group, 931 14th

Street, Denver, CO 80202 to request a printed copy.

We value you as a customer and look forward to continuing to serve your communication needs. If you have

any questions, please contact customer service at the number

ATTACHMENT G

http://www.donotcall.gov/

http://www.centurylink.com/privacy/

http://www.centurylink.com/LifeLine/

LIFELINE WEB LINK

ATTACHMENT G

Lifeline

Support programs for qualifying low-income customers

Overview Qualify

Apply

Overview

Lifeline is the FCC's program to help make communications services moreaffordable for low-income consumers. Lifeline provides subscribers a discount onmonthly telephone service purchased from participating providers in themarketplace. Subscribers can also purchase discounted broadband fromparticipating providers. The discounts, which can be applied to stand-alonebroadband, bundled voice-broadband packages - either fixed or mobile - and stand-alone voice service - help ensure that low-income consumers can afford 21st-century broadband and the access it provides to jobs, education and opportunities.

You can only use Lifeline for either phone or broadband, but not both.

Lifeline discounts on voice services are available to participants of both stateand federally recognized aid programs.Lifeline discounts on broadband services are available to participants offederally-recognized aid programs and is limited to certain broadband services.Broadband speeds must be 15 Mbps download and 2 Mbps upload or faster toqualify.If you purchase voice and qualifying broadband services, the federal Lifelinediscount will apply to your qualifying broadband service.If you purchase voice service and a non-qualifying broadband service, you mayreceive both state and federal Lifeline discounts on your voice service.

Standard Lifeline—provides federal monthly support of $9.25. In some states,additional monthly support is also available

COMMUNITY

Programs for Customerswith Disabilities

Lifeline

E-Rate

Refer a Friend RewardProgram

Foundation

CenturyLink and theEnvironment

Sponsorships

Diversity

Community DevelopmentPrograms

Success Stories

Contact Us

ATTACHMENT G

http://www.centurylink.com/aboutus/community/community-development/programs-for-customers-with-disabilities.html


http://www.centurylink.com/aboutus/community/community-development/e-rate.html

http://www.centurylink.com/aboutus/community/community-development/refer-a-friend-rewards.html

http://www.centurylink.com/aboutus/community/community-development/refer-a-friend-rewards.html

http://www.centurylink.com/aboutus/community/foundation.html

http://www.centurylink.com/aboutus/community/centurylink-and-the-environment.html

http://www.centurylink.com/aboutus/community/centurylink-and-the-environment.html

http://www.centurylink.com/aboutus/community/sponsorships.html

http://www.centurylink.com/aboutus/community/diversity.html

http://www.centurylink.com/aboutus/community/community-development.html

http://www.centurylink.com/aboutus/community/community-development.html

http://www.centurylink.com/aboutus/community/success-stories.html

http://www.centurylink.com/help/contact

Tribal Lifeline—offers a deeper monthly discount as well as installation assistancethrough the Link-Up program to qualifying customers who live on federally-recognized Tribal lands.

How do I qualify for a Lifeline discount?

Lifeline is available to qualified customers in every U.S. state. Qualificationrequirements vary by state. Select your state from the drop down box below in orderto obtain state specific information on how to apply.

Please be aware that only one Lifeline discount is available per household, even ifthe household has more than one telephone or broadband account, includinglandline or wireless service. Under the Lifeline program, a household is defined asany individual or group of individuals who live together at the same address andshare income and expenses. The Lifeline discount is not transferable and onlyeligible customers may enroll in the program. Documentation of eligibility is requiredto enroll. Customers who willfully make false statements in order to obtain Lifelineservice can be punished by fine or imprisonment and can be barred from theprogram.

How to apply for Lifeline assistance

Please select your state from the options below or contact us at 1-855-954-6546 (1-888-833-9522 former Qwest territories).

Applying for Lifeline - Frequently Asked Questions

Examples of Qualifying Documentation

Choose:

Get Connected.See what's next for CenturyLink.

About Us Careers Investor Relations Legal Legal Notices Privacy Policy Site Map Tariffs Customers with Disabilities

Store Locator Yellow Pages Referral Program CenturyLink Retailer Guide to Home Technology Fed Govt State & Local Govt Education

ATTACHMENT G

http://www.centurylink.com/asset/aboutus/downloads/community/lifeline/Applying_For_Lifeline_FAQ.pdf



http://www.centurylink.com/asset/aboutus/downloads/community/lifeline/Qualifying_Documentation_Examples.pdf



https://www.linkedin.com/company/centurylink

https://twitter.com/CenturyLink

https://www.youtube.com/user/CenturyLink

https://www.facebook.com/CenturyLink/

http://www.centurylink.com/aboutus.html

http://www.centurylink.com/aboutus/companyinformation/careers/

http://ir.centurylink.com/

http://www.centurylink.com/aboutus/legal.html

http://www.centurylink.com/legal/

http://www.centurylink.com/aboutus/legal/privacy-policy.html

http://www.centurylink.com/sitemap.html

http://www.centurylink.com/aboutus/legal/tariff-library.html


http://storelocator.centurylinkapps.com/index.cfm

http://www.centurylinkyellowpages.com/

https://www.centurylinkreferafriend.com/PIOR/

http://www.localinternetservice.com/

http://www.centurylink.com/beyondthewires/

http://www.centurylink.com/business/federal-gov/

http://www.centurylink.com/business/state-and-local-gov/

http://www.centurylink.com/business/education/

Partners

For Home Small Business Medium - Enterprise Wholesale Feedback

© 2018 CenturyLink. All Rights Reserved. Third party marks are the property of their respective owners.

ATTACHMENT G

http://www.centurylink.com/business/partners/

http://www.centurylink.com/home/

http://www.centurylink.com/small-business/

http://www.centurylink.com/business.html

http://www.centurylink.com/wholesale/

https://secure.opinionlab.com/ccc01/comment_card_d.asp

SOUTH DAKOTA NEWSPAPERS DATE SENT

Aberdeen American News 11/07/2017

Alcester Union & Hudsonite 11/09/2017

Alexandria Herald 11/09/2017

Arlington Sun 11/09/2017

Belle Fourch Post 11/08/2017

Beresford Republic 11/09/2017

Brookings Register 11/06/2017

Bryant Dakotan 11/08/2017

Brandon Valley Challenger 11/08/2017

Canton Sioux Valley News 11/09/2017

Castlewood Hamlin County Republican 11/08/2017

Chamberlain Central Dakota Times 11/08/2017

Chamberlain/Oacoma Sun 11/08/2017

Clark County Courier 11/08/2017

Clear Lake Courier 11/08/2017

Conde Courier 11/08/2017

Custer County Chronicle 11/08/2017

Dokata Dunes North Sioux City Times 11/08/2017

DeSmet News 11/08/2017

Dell Rapids Tribune 11/08/2017

Doland Times-Record 11/08/2017

Eagle Butte West River Eagle 11/09/2017

Elk Point Leader 11/09/2017

Elkton Record 11/09/2017

Emery Enterprise 11/09/2017

Estelline Journal 11/08/2017

Faulkton Faulk Co Record 11/08/2017

Flandreau Moody County Enterprise 11/08/2017

Garretson Gazette 11/09/2017

Groton Dakota Press 11/08/2017

Hayti Hamlin Hearald Enterprise 11/08/2017

Hill City Prevailer News 11/08/2017

Howard Miner Pioner 11/09/2017

Huron Plainsman 11/07/2017

Ipswich Tribune 11/08/2017

Lake Preston Times 11/08/2017

Lemmon Dakota Herald 11/06/2017

Lennox Independent 11/09/2017

Leola McPherson County Herald 11/08/2017

Madison Daily Leader 11/06/2017

McLaughlin Carson/Sioux Co Messanger 11/09/2017

Milbank Grant County Review 11/08/2017

Miller Press 11/08/2017

ATTACHMENT G

SOUTH DAKOTA NEWSPAPERS DATE SENT

Minnehaha Messenger 11/09/2017

Mitchell Daily Republic 11/06/2017

Mobridge Tribune 11/08/2017

Montrose Herald 11/10/2017

New Underwood Post 11/09/2017

Onida Watchman 11/09/2017

Pierre Capital Journal 11/06/2017

Plankinton South Dakota Mail 11/09/2017

Pollock Prairie Pioneer 11/09/2017

Presho Lyman Co Herald 11/08/2017

Rapid City Journal 11/06/2017

Redfield Press 11/08/2017

Sioux Falls Argus Leader 11/06/2017

Spearfish Black Hills Pioneer 11/06/2017

Sturgis Meade Times Tribune 11/08/2017

Tea Weekly 11/10/2017

Timber Lake Topic 11/09/2017

Tyndall Tribune & Register 11/08/2017

Vermillion Plain Talk 11/10/2017

Volga Tribune 11/09/2017

Watertown Public Opinion 11/06/2017

Waubay Clipper 11/11/2017

Wessington Springs True Dakotan 11/08/2017

Wilmot Enterprise 11/09/2017

Woonsocket Weekly Journal 11/09/2017

Yankton County Observer 11/10/2017

Yankton Press & Dakotan 11/06/2017

ATTACHMENT G

Phone and Internet Discounts

Available to CenturyLink Customers

The South Dakota Public Utilities Commission designated CenturyLink as an Eligible Telecommunications Carrier within its service area for universal service purposes. CenturyLink’s basic local service rates for residential voice lines are $21.25 per month and business services are $32.00-$38.40 per month. Specific rates will be provided upon request.

CenturyLink participates in a government benefit program (Lifeline) to make residential telephone or qualifying broadband service more affordable to eligible low-income individuals and families. Eligible customers are those that meet eligibility standards as defined by the FCC and state commissions. Residents who live on federally recognized Tribal Lands may qualify for additional Tribal benefits if they participate in certain additional federal eligibility programs. The Lifeline discount is available for only one telephone or qualifying broadband service per household, which can be either wireline or wireless service. Broadband speeds must be 15 Mbps download and 2 Mbps upload or faster to qualify.

Lifeline discounts include a transfer restriction (port freeze). This means that you are unable to obtain the Lifeline discount on service with another provider for a period of time. The length of time depends on the services you purchase – 60 days for voice telephone service, 12 months for qualifying broadband service. Certain exceptions to the transfer restrictions may apply. See http://www.lifelinesupport.org/ls/change-my-company.aspx for more information.

A household is defined for the purposes of the Lifeline program as any individual or group of individuals who live together at the same address and share income and expenses. Lifeline service is not transferable, and only eligible consumers may enroll in the program. Consumers who willfully make false statements in order to obtain Lifeline telephone or broadband service can be punished by fine or imprisonment and can be barred from the program.

If you live in a CenturyLink service area, please call 1-888-833-9522 or visit centurylink.com/lifeline with questions or to request an application for the Lifeline program.

ATTACHMENT G

http://www.lifelinesupport.org/ls/change-my-company.aspx

http://www.lifelinesupport.org/ls/change-my-company.aspx

Thursday, November 30, 2017 04:07 PM

Invoice

Page 1

Louisiana Press Association404 Europe Street

Baton Rouge,LA 70802Voice (225) 344-9309 Fax (225) 344-9344

Agency CenturyLink LifelineOrder 17112CC0_SD

Ad SizeRun Date Rate NameRate TotalCaption

Client CenturyLink Lifeline

PO Number SD Qwest notices

Color

Jennifer Mercer

NewspaperDisc.

100 CenturyLink DriveMailstop: 6TS115Monroe, LA 71203-

Invoice Date 11/30/2017

Reps Erin Palmintier

South Dakota Newspaper ServicesSDNPA/Pierre Capital Journal County Hughes

2 x 911/06/2017 $232.92CL$12.94 $0.00 0.0000%Newspaper Total $232.92

Newspaper Net $232.92

SDNPA/Rapid City Journal County Pennington

2 x 911/06/2017 $1,206.90CL$67.05 $0.00 0.0000%Newspaper Total $1,206.90

Newspaper Net $1,206.90

SDNPA/Sioux Falls Argus Leader County Minnehaha



SDPA/Aberdeen American News County Brown



SDPA/Alcester Union & Hudsonite County Union



SDPA/Alexandria Herald County Hanson



Payment due upon receipt to Louisiana Press Association. Please pay from this invoice. The Louisiana Press Association (LPA) is not liable for any error in placement of advertising to an extent greater

than the cost of the space occupied, or that would have been occupied, by error(s) due to LPA action(s) or inaction(s). Claims against the LPA for adjustments must be made not later than the earlier of three days from

the receipt of the tear sheets or within three days of having knowledge of the error(s). LPA does not assume any liability for error(s) made by the newspapers in which the advertisements are placed.

A d -V a n ta g e ™ v e rs io n 7 .6 4 b y C u s to m w a re , In c . C o p y r ig h t 2 0 0 1 -2 0 1 7 R e g is te re d T o : L o u is ia n a P re s s A s s o c ia t io n

Attachment G


Invoice

Page 2







Color

Jennifer Mercer

NewspaperDisc.




SDPA/Arlington Sun County Brookings/Kingsbury



SDPA/Belle Fourche Butte Co. Post County Butte



SDPA/Beresford Republic County Lincoln/Union



SDPA/Brandon Valley Challenger County Minnehaha



SDPA/Brookings Register County Brookings



SDPA/Bryant Dakotan County Hamlin







Attachment G


Invoice

Page 3







Color

Jennifer Mercer

NewspaperDisc.




SDPA/Canton Sioux Valley News County Lincoln



SDPA/Castlewood Hamlin County Republican County Hamlin



SDPA/Chamberlain Central Dakota Times County Brule



SDPA/Chamberlain/Oacoma Sun County Brule



SDPA/Clark County Courier County Clark



SDPA/Clear Lake Courier County Deuel







Attachment G


Invoice

Page 4







Color

Jennifer Mercer

NewspaperDisc.




SDPA/Conde Courier County Spink



SDPA/Custer County Chronicle County Custer



SDPA/Dakota Dunes North Sioux City Times County union



SDPA/De Smet News County Kingsbury



SDPA/Dell Rapids Tribune County Minnehaha



SDPA/Doland Times-Record County Spink







Attachment G


Invoice

Page 5







Color

Jennifer Mercer

NewspaperDisc.




SDPA/Eagle Butte West River Eagle County Dewey/Ziebach



SDPA/Elk Point Southern Union Co. Leader-Courier County Union



SDPA/Elkton Record County Brookings



SDPA/Emery Enterprise County Hanson



SDPA/Estelline Journal County Hamlin



SDPA/Faulkton Faulk Co. Record County Faulk







Attachment G


Invoice

Page 6







Color

Jennifer Mercer

NewspaperDisc.




SDPA/Flandreau Moody County Enterprise County Moody



SDPA/Garretson Gazette County Minnehaha



SDPA/Groton Dakota Press County Brown



SDPA/Hayti Hamlin Co. Herald-Enterprise County Hamlin



SDPA/Hill City Prevailer News County Pennington



SDPA/Howard Miner Co. Pioneer County Miner







Attachment G


Invoice

Page 7







Color

Jennifer Mercer

NewspaperDisc.




SDPA/Huron Plainsman County Beadle



SDPA/Ipswich Tribune County Edmunds



SDPA/Lake Preston Times County Kingsbury



SDPA/Lemmon Dakota Herald County Perkins



SDPA/Lennox Independent County Lincoln



SDPA/Leola McPherson County Herald County McPherson







Attachment G


Invoice

Page 8







Color

Jennifer Mercer

NewspaperDisc.




SDPA/Madison Daily Leader County Lake



SDPA/McLaughlin Corson/Sioux Co. News-Messenger County Corson



SDPA/Milbank Grant County Review County Grant



SDPA/Miller Press County Hand



SDPA/Minnehaha Messenger County Minnehaha



SDPA/Mitchell Daily Republic County Davison







Attachment G


Invoice

Page 9







Color

Jennifer Mercer

NewspaperDisc.




SDPA/Mobridge Tribune County Walworth



SDPA/Montrose Herald County McCook



SDPA/New Underwood Post/Revelette Pub. County Pennington



SDPA/Onida Watchman County Sully



SDPA/Plankinton South Dakota Mail County Aurora



SDPA/Pollock Prairie Pioneer County Campbell







Attachment G


Invoice

Page 10







Color

Jennifer Mercer

NewspaperDisc.




SDPA/Presho Lyman Co. Herald County Lyman



SDPA/Redfield Press County Spink



SDPA/Spearfish Black Hills Pioneer County Lawrence



SDPA/Sturgis Meade Co. Times Tribune County Meade



SDPA/Tea Weekly County Lincoln



SDPA/Timber Lake Topic County Dewey







Attachment G


Invoice

Page 11







Color

Jennifer Mercer

NewspaperDisc.




SDPA/Tyndall Tribune and Register County Bon Homme



SDPA/Vermillion Plain Talk County Clay



SDPA/Volga Tribune County Brookings



SDPA/Watertown Public Opinion County Codington



SDPA/Waubay Clipper County Day



SDPA/Wessington Springs True Dakotan County Beadle/Hand







Attachment G


Invoice

Page 12







Color

Jennifer Mercer

NewspaperDisc.




SDPA/Wilmont Enterprise County Roberts



SDPA/Woonsocket Weekly Journal County Sanborn



SDPA/Yankton County Observer County Yankton



SDPA/Yankton Daily Press Dakotan County Yankton



Total Advertising $12,575.13

Discounts $0.00

Total Invoice $12,575.13

Payments $0.00

Adjustments $0.00

Balance Due $12,575.13

$0.00Tax: USAMisc Charge $0.00





Attachment G

Tuesday, May 30, 2017 08:51 AM

Invoice

Page 1






PO Number Tribal Qwest SD

Color

Jennifer Mercer

NewspaperDisc.




South Dakota Newspaper ServicesSDPA/Chamberlain Central Dakota Times County Brule

2 x 9CenturyLink offers telephone assistance to individuals living on Tribal Lands

05/10/2017 $137.70CL$7.65 $0.00 0.0000%

Newspaper Total $137.70


SDPA/Chamberlain/Oacoma Sun County Brule


05/10/2017 $126.00CL$7.00 $0.00 0.0000%



SDPA/Eagle Butte West River Eagle County Dewey/Ziebach


05/11/2017 $157.68CL$8.76 $0.00 0.0000%



SDPA/Flandreau Moody County Enterprise County Moody


05/10/2017 $206.46CL$11.47 $0.00 0.0000%







Attachment G


Invoice

Page 2







Color

Jennifer Mercer

NewspaperDisc.




SDPA/McLaughlin Corson/Sioux Co. News-Messenger County Corson


05/11/2017 $90.00CL$5.00 $0.00 0.0000%



SDPA/Mobridge Tribune County Walworth


05/10/2017 $194.76CL$10.82 $0.00 0.0000%



SDPA/Rapid City Native Sun News County Pennington


05/10/2017 $401.22CL$22.29 $0.00 0.0000%



SDPA/Sisseton Courier County Roberts


05/09/2017 $142.92CL$7.94 $0.00 0.0000%







Attachment G


Invoice

Page 3







Color

Jennifer Mercer

NewspaperDisc.




SDPA/Timber Lake Topic County Dewey


05/11/2017 $120.78CL$6.71 $0.00 0.0000%



SDPA/Wilmont Enterprise County Roberts


05/11/2017 $111.24CL$6.18 $0.00 0.0000%



Total Advertising $1,688.76

Discounts $0.00

Total Invoice $1,688.76

Payments $0.00

Adjustments $0.00

Balance Due $1,688.76

$0.00Tax: USA





Attachment G

OMB APPROVAL EDITION 3060-0819FCC FORM 5629

Lifeline Program Application Form

Universal Service Administrative Company | www.lifelinesupport.orgPage 1 of 6

RulesIf you qualify, your household can get Lifeline for phone or internet service, but not both.

• If you get Lifeline for phone service, you can get the benefit for one mobile phone or one home phone, but not both.

• If you get Lifeline for internet service, you can get the benefit for your mobile phone or your home connection, but not both.

• If you get Lifeline for bundled phone and internet service, you can get the benefit for your mobile phone bundled service or your home bundled service, but not both.

Your household cannot get Lifeline from more than one phone or internet company.

You are only allowed to get one Lifeline benefit per household, not per person. If more than one person in your household gets Lifeline, you are breaking the FCC’s rules and will lose your benefit.

What is a household?A household is a group of people who live together and share income and expenses (even if they are not related to each other).

Do not give your benefit to another personLifeline is non-transferable. You cannot give your Lifeline benefit to another person, even if they qualify.

Be honest on this formYou must give accurate and true information on this form and on all Lifeline-related forms or questionnaires. If you give false or fraudulent information, you will lose your Lifeline benefit (i.e., de-enrollment or being barred from the program) and the United States government can take legal actions against you. This may include (but is not limited to) fines or imprisonment.

You may need to show other documentsIf your phone or internet company is not able to prove you or someone in your household qualify using this form and electronic databases, you may need to show an official document from one of the government qualifying programs or to prove your annual income. You can submit copies of your official documents with this application or wait until your phone or internet company asks you for them. To add them now, include the documents in option 1 or option 2 below:

1. If you qualify through a government program: copies of your state ID card and an official documentfrom the programs you are qualifying though (your SNAP card, Medicaid card, etc.)

2. If you qualify through your income: copies of your state ID card and pay stubs for 3 consecutive months (or other accepted documents).

Visit lifelinesupport.org to see the full list of accepted documents.

ApplyTo apply for a Lifeline benefit, fill out every section of this form, initial every agreement statement, and sign the last page.

To apply, bring or mail this form to your phone or internet company.

1. About LifelineLifeline is a federal benefit that lowers the monthly cost of phone or internet service.

Return this form to:CenturyLink FAX: 402-998-7341P.O. Box 2738 Customer Service: 888-833-9522 Omaha, NE 68103-2738 Email: [email protected]

ATTACHMENT G




What is your full legal name? The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

What is your phone number (if you have one)?

First

2. Your InformationAll fields are required unless indicated. Use only CAPITALIZED LETTERS and black ink to fill out this form.

* Tribal lands include any federally recognized Indian tribe’s reservation, pueblo, or colony, including former reservations in Oklahoma; Alaska Native regions established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688); Indian allotments; Hawaiian Home Lands—areas held in trust for Native Hawaiians by the state of Hawaii, pursuant to the Hawaiian Homes Commission Act, 1920 July 9, 1921, 42 Stat. 108, et. seq., as amended; and any land designated as such by the Commission for purposes of this subpart pursuant to the designation process in the FCC’s Lifeline rules.

What is your date of birth?

Month Day Year

What is your email address (if you have one)?

What are the last 4 numbers of your Social Security Number (SSN)?

If you do not have a SSN, what is your Tribal Identification Number?

Middle (optional) Suffix (optional)

Last

What is your home address? (The address where you will get service. Do not use a P.O. Box)

Street Number and Name

City Zip CodeState

Apt., Unit, etc.

Is this a temporary address? Yes No Check if you live on Tribal Lands*

What is your mailing address? (Only fill this out if it is not the same as your home address.)

What is the best way to reach you? email phone text message mail


City Zip CodeState

Apt., Unit, etc.

ATTACHMENT G




2. Your Information (continued)Only fill this section out if you are applying through a child or dependent.

Check if you are qualifying through a child or dependent in your household. If so, answer the following questions:

What is their full legal name?

Check if they live on Tribal Lands*

First


Last

What is their date of birth?

Month Day Year

What are the last 4 numbers of their Social Security Number (SSN)?

If they do not have a SSN, what is their Tribal Identification Number?

ATTACHMENT G




Check all programs that you or someone in your household have:

Supplemental Nutrition Assistance Program (SNAP) (Food Stamps)

Supplemental Security Income (SSI)

Medicaid

Federal Public Housing Assistance (FPHA)

Veterans Pension or Survivors Benefit Programs

Tribal Specific Programs

Bureau of Indian Affairs (BIA) General Assistance

Tribal Temporary Assistance for Needy Families (Tribal TANF)

Food Distribution Program on Indian Reservations (FDPIR)

Tribal Head Start (only households that meet the income qualifying standard)

Qualify through a government program:

Or

Qualify through your income: (Only fill this out if you do not qualify through a government program.)

3. Qualify for LifelineFill out this section to show that you, your dependent, or someone in your household qualifies for Lifeline.

You can qualify through some government assistance programs or through your income (you do not need to qualify through both).

Including you, how many people live in your household? (check one)

Is your income the same or less than the amount listed for your state and household size? (only check yes or no next to your household size)

All 48 States & DC (not Alaska and Hawaii)

Alaska Hawaii

1 $16,389 $20,493 $18,846 Yes No

2 $22,221 $27,783 $25,555.50 Yes No

3 $28,053 $35,073 $32,265 Yes No

4 $33,885 $42,363 $38,974.50 Yes No

5 $39,717 $49,653 $45,684 Yes No

6 $45,549 $56,943 $52,393.50 Yes No

7 $51,381 $64,233 $59,103 Yes No

8 $57,213 $71,523 $65,812.50 Yes No

If more than 8, add this amount for each extra person:

Add $5,832 Add $7,290Add $6,709.50 Yes No

135% of the 2018 Federal Poverty Guidelines *The Federal Poverty Guidelines are typically updated at the end of January.

ATTACHMENT G




Signature Today’s Date

4. AgreementI agree, under penalty of perjury, to the following statements:

You must initial next to each statement.

What is the agent’s full legal name? The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

What is the agent’s USAC ID number?

First Last Middle (optional)

5. Agent InformationAnswer only if a sales person submits this form.

What is the agent’s date of birth?

Month Day Year

Suffix

Initial

I (or my dependent or other person in my household) currently get benefits from the government program(s) listed on this form or my annual household income is 135% or less than the Federal Poverty Guidelines (the amount listed in the Federal Poverty Guidelines table on this form).

Initial

I agree that if I move I will give my service provider my new address within 30 days.

Initial

I understand that I have to tell my service provider within 30 days if I do not qualify for Lifeline anymore, including: 1) I, or the person in my household that qualifies, do not qualify through a government

program or income anymore. 2) Either I or someone in my household gets more than one Lifeline benefit (including, more

than one Lifeline broadband internet service, more than one Lifeline telephone service, or both Lifeline telephone and Lifeline broadband internet services).

Initial

I know that my household can only get one Lifeline benefit and, to the best of my knowledge, my household is not getting more than one Lifeline benefit.

Initial

I agree that my service provider can give the Lifeline Program administrator all of the information I am giving on this form. I understand that this information is meant to help run the Lifeline Program and that if I do not let them give it to the Administrator, I will not be able to get Lifeline benefits.

Initial

All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.

Initial

I know that willingly giving false or fraudulent information to get Lifeline Program benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program.

Initial

My service provider may have to check whether I still qualify at any time. If I need to recertify (renew) my Lifeline benefit, I understand that I have to respond by the deadline or I will be removed from the Lifeline Program and my Lifeline benefit will stop.

Initial

I was truthful about whether or not I am a resident of Tribal lands, as defined in section 2 of this form.

I consent to let USAC contact me at my Lifeline phone number for important reminders and updates to my Lifeline service. Message and data rates may apply. Text STOP to end messages.

ATTACHMENT G




Notice PAPERWORK REDUCTION ACT NOTICE: Section 54.410 of the Federal Communications Commission’s rules requires all Lifeline subscribers to demonstrate their eligibility to receive Lifeline services. This collection of information stems from the Commission’s authority under Section 254 of the Communications Act of 1934, as amended, 47 U.S.C. §254. Using this authority, the FCC has designated USAC as the permanent Lifeline Administrator. The FCC has published rules detailing how consumers can qualify for Lifeline services and what Lifeline services they may receive (47 CFR §54.400 et seq.). The data provided in response to this information collection will be used by USAC to verify the applicant’s eligibility for Lifeline services.

We have estimated that each response to this collection of information will take, on average, between 0.25 and 0.75 hours. Our estimate includes the time to read the questions, look through existing records, gather the required data, and actually complete and review the form or response. If you have any comments on this estimate, or how we can improve the collection and reduce the burden it causes you, please write to the Federal Communications Commission, OMD-PERM, Paperwork Reduction Project (3060-0819), Washington, D.C. 20554. We also will accept your comments via the Internet if you send them to [email protected]. Please DO NOT SEND COMPLETED DATA COLLECTION FORMS TO THIS ADDRESS.

Remember – You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid Office of Management and Budget (OMB) control number. This collection has been assigned an OMB control number of 3060-0819.

The Commission is authorized under the Communications Act of 1934, as amended, to collect the information we request on this form. If we believe there may be a violation or potential violation of a statute or a Commission regulation, rule, or order, your response may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order.

If you do not provide the information we request on this form, you will not be eligible to receive Lifeline services under the Lifeline Program rules, 47 C.F.R. §§ 54.400-54.423.

The foregoing Notice is required by the Paperwork Reduction Act of 1995, P.L. No. 104-13, 44 U.S.C. § 3501, et seq.

PRIVACY ACT STATEMENT: The Privacy Act is a law that requires the Federal Communications Commission (FCC) and the Universal Service Administrative Company (USAC) to explain why we are asking individuals for personal information and what we are going to do with this information after we collect it.

Authority: Section 254 of the Communications Act (47 U.S.C. § 254), as amended, 47 U.S.C. §254, authorizes the FCC to operate the Lifeline program. Using this authority, the FCC has designated USAC as the permanent Lifeline Administrator. The FCC has published rules detailing how consumers can qualify for Lifeline services and what Lifeline services they may receive (47 CFR §54.400 et seq.).

Purpose: We are collecting this personal information so we can verify that you qualify for the Lifeline program and so we can efficiently provide Lifeline services to you. We access, maintain and use your personal information in the manner described in the Lifeline System of Records Notice (SORN), FCC/WCB-1, which we have published in 82 Fed. Reg. 38686 (Aug. 15, 2017).

Routine Uses: We may share the personal information you enter into this form with other parties for specific purposes, such as: with contractors that help us operate the Lifeline program; with other federal and state government agencies that help us determine your Lifeline eligibility; with the telecommunications companies that provide you Lifeline service; and with law enforcement and other officials investigating potential violations of Lifeline rules.

A complete listing of the ways we may use your information is published in the Lifeline SORN described in the “Purpose” paragraph of this statement.

Disclosure: You are not required to provide the information we are requesting, but if you do not, you will not be eligible to receive Lifeline services under the Lifeline Program rules, 47 C.F.R. §§ 54.400-54.423.

ATTACHMENT G

OMB APPROVAL EDITION 3060-0819

Lifeline Program Household Worksheet

Page 1 of 3

FCC FORM 5631

Universal Service Administrative Company | www.lifelinesupport.org

What this worksheet is forUse this worksheet if someone else at your address gets Lifeline. The answers to these questions will help you find out if there is more than one household at your address.

What is a household?A household is a group of people who live together and share income and expenses (even if they are not related to each other).

Examples of one household: • A married couple who live together are one household. They must share one Lifeline

benefit. • A parent/guardian and child who live together are one household. They must share one

Lifeline benefit. • An adult who lives with friends or family who financially support him/her are one

household. They must share one Lifeline benefit.

Examples of more than one household: • 4 roommates who live together but do not share money are 4 households. They can have

one Lifeline benefit each, 4 total. • 30 seniors who live in an assisted-living home are 30 households. They can have one

Lifeline benefit each, 30 total.

Household expensesA household shares expenses. Household expenses include, but are not limited to, food, healthcare expenses, and the cost of renting or paying a mortgage on your place of residence and utilities.

IncomeHouseholds share income. Income includes salary, public assistance benefits, social security payments, pensions, unemployment compensation, veteran’s benefits, inheritances, alimony, child support payments, worker’s compensation benefits, gifts, and lottery winnings.

About LifelineLifeline is a benefit that lowers the monthly cost of phone or internet service (not both). You are only allowed to get one Lifeline benefit per household, not per person.

ATTACHMENT G



Page 2 of 3

FCC FORM 5631


You do not qualify for Lifeline because someone in your household already gets the benefit. You are only allowed to get one Lifeline discount per household, not per person.

Check this box

You can apply for Lifeline. You live in a household that does not get Lifeline yet. Please initial line B on page 3, and sign and date the worksheet.

Check this box

Can you apply?Follow this decision tree to confirm if you qualify for the Lifeline Program.

You can apply for Lifeline. You live at an address with more than one household and your household does not get Lifeline yet. Please initial lines A and B on page 3,

and sign and date the worksheet.

Check this box

2. Do they get Lifeline? Yes No

1. Do you live with another adult?Adults are people who are 18 years old or older, or who are emancipated minors. This can include a spouse, domestic partner, parent, adult son or daughter, adult in your family, adult roommate, etc.

Yes No

3. Do you share money (income and expenses) with them?This can be the cost of bills, food, etc., and income. If you are married, you should check yes for this question.

Yes No

If yes, answer question 3

If yes, answer question 2

What is your full legal name? The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

First


Last

What is your home address? (The address where you will get service. Do not use a P.O. Box)


City Zip CodeState

Apt., Unit, etc.

ATTACHMENT G



Page 3 of 3

FCC FORM 5631


Notice NOTICE: Section 54.410 of the Federal Communications Commission’s rules requires all Lifeline subscribers to demonstrate their eligibility to receive Lifeline services. If more than one person at the same address is applying for Lifeline service, all applicants must submit a Household Worksheet. This collection of information stems from the Commission’s authority under Section 254 of the Communications Act of 1934, as amended, 47 U.S.C. §254. Using this authority, the FCC has designated USAC as the permanent Lifeline Administrator. The FCC has published rules detailing how consumers can qualify for Lifeline services and what Lifeline services they may receive (47 CFR §54.400 et seq.). The data provided in response to this information collection will be used by USAC to verify the applicant’s eligibility for Lifeline services.

We have estimated that each response to this collection of information will take, on average, 0.25 hours. Our estimate includes the time to read and complete the form and review the form or response. If you have any comments on this estimate, or how we can improve the collection and reduce the burden it causes you, please write to the Federal Communications Commission, OMD-PERM, Paperwork Reduction Project (3060-0819), Washington, D.C. 20554. We also will accept your comments via the Internet if you send them to [email protected]. Please DO NOT SEND COMPLETED DATA COLLECTION FORMS TO THIS ADDRESS.

Remember – You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid Office of Management and Budget (OMB) control number. This collection has been assigned an OMB control number of 3060-0819.

The Commission is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. We will use the information that you provide to determine your eligibility for Lifeline services. If we believe there may be a violation or potential violation of a statute or a Commission regulation, rule, or order, your form may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order. In certain cases, the information in your form may be disclosed to the Department of Justice, court, or other adjudicative body when (a) the Commission; (b) any employee of the Commission; or (c) the United States government, is a party to a proceeding before the body or has an interest in the proceeding.

If you do not provide the information we request on this form, you will not be eligible to receive Lifeline services under the Lifeline Program rules, 47 C.F.R. §§ 54.400-54.423.

The foregoing Notice is required by the Paperwork Reduction Act of 1995, P.L. No. 104-13, 44 U.S.C. § 3501, et seq.

PRIVACY ACT STATEMENT: The Privacy Act is a law that requires the Federal Communications Commission (FCC) and the Universal Service Administrative Company (USAC) to explain why we are asking individuals for personal information and what we are going to do with this information after we collect it.

Authority: Section 254 of the Communications Act (47 U.S.C. § 254), as amended, 47 U.S.C. §254, authorizes the FCC to operate the Lifeline program. Using this authority, the FCC has designated USAC as the permanent Lifeline Administrator. The FCC has published rules detailing how consumers can qualify for Lifeline services and what Lifeline services they may receive (47 CFR §54.400 et seq.).

Purpose: We are collecting this personal information so we can verify that you qualify for the Lifeline program and so we can efficiently provide Lifeline services to you. We access, maintain and use your personal information in the manner described in the Lifeline System of Records Notice (SORN), FCC/WCB-1, which we have published in 82 Fed. Reg. 38686 (Aug. 15, 2017).

Routine Uses: We may share the personal information you enter into this form with other parties for specific purposes, such as: with contractors that help us operate the Lifeline program; with other federal and state government agencies that help us determine your Lifeline eligibility; with the telecommunications companies that provide you Lifeline service; and with law enforcement and other officials investigating potential violations of Lifeline rules.

A complete listing of the ways we may use your information is published in the Lifeline SORN described in the “Purpose” paragraph of this statement.

Disclosure: You are not required to provide the information we are requesting, but if you do not, you will not be eligible to receive Lifeline services under the Lifeline Program rules, 47 C.F.R. §§ 54.400-54.423.

Initial

A I live at an address with more than one household.

Initial

B I understand that the one-per-household limit is a Federal Communications Commission (FCC) rule and I will lose my Lifeline benefit if I break this rule.

AgreementPlease initial the agreement below and sign and date this worksheet. Submit this worksheet to your service provider with your Lifeline Program Application Form.

Signature Today’s Date

I consent to let USAC contact me at my Lifeline phone number for important reminders and updates to my Lifeline service. Message and data rates may apply. Text STOP to end messages.

ATTACHMENT G


Programa de Lifeline: Forma de Aplicación

Page 1 of 6

FCC FORM 5629


ReglasSi calificas, tu hogar puede obtener Lifeline para servicio de teléfono o internet, pero no ambos.

• Si obtienes Lifeline para servicio telefónico, puedes obtener el beneficio para un teléfono móvil o telefonía fija, pero no para los dos.

• Si obtienes Lifeline para servicio de internet, puedes obtener el beneficio para internet móvil o internet fijo, pero no para los dos.

• Si obtienes Lifeline para un paquete de servicio de teléfono e internet, puedes obtener el beneficio para un paquete de teléfono móvil o un paquete residencial, pero no para los dos.

Tu hogar no puede obtener Lifeline a través de más de una compañía telefónica o de internet.

Sólo se permite un beneficio de Lifeline por hogar, no por persona. Si más de una persona en tu hogar recibe Lifeline, estas infringiendo a las reglas de la FCC y perderás a tu beneficio.

¿Qué es un hogar?Un hogar es un grupo de personas que viven juntas y comparten ingresos y gastos (aunque no sean parientes).

No le des tu beneficio a otra personaLifeline no es transferible. No puedes darle tu beneficio de Lifeline a otra persona, aunque califique.

Se honesto en esta formaTienes que dar información precisa y verdadera en esta forma y en todos las formas o cuestionarios relacionados con Lifeline. Si das información falsa o fraudulenta, perderás a tu beneficio de Lifeline (es decir, cancelación de tu suscripción o exclusión del programa) y el gobierno de los Estados Unidos podrá tomar acciones legales en tu contra. Esto puede incluir (per no es limitado a) multas o encarcelamiento.

Es posible que necesites mostrar otros documentosSi tu compañía de teléfono o internet no puede comprobar que tú o alguien en tu hogar califica usando solamente esta forma y bases de datos, es posible que necesites mostrar un documento oficial de uno de los programas de gobierno que califican o demonstrar a tus ingresos anuales. Puedes entregar copias de tus documentos oficiales con esta aplicación o esperar hasta que tu compañía de teléfono o internet te los pida. Para agregarlos ahora, incluye a los documentos en la opción 1 o la opción 2:

1. Si calificas a través de un programa de gobierno: copias de tu tarjeta de identificación estatal y de un documento oficial del programa que estas usando para calificar (tu tarjeta SNAP, tarjeta deMedicaid, o otro)

2. Si calificas a través de tus ingresos: copias de tu tarjeta de identificación estatal y comprobantes de pago para 3 meses consecutivos (o otros documentos aceptados)

Visita a lifelinesupport.org para ver la lista completa de documentos aceptados.

AplicarPara aplicar por un beneficio de Lifeline, llena todas las secciones de esta forma, iníciala a cada declaración del acuerdo, y firma a la última página.

Para aplicar, trae o envía por correo esta forma a tu compañía de teléfono o internet.

1. Sobre LifelineLifeline es un beneficio federal que reduce el costo mensual de servicio telefónico o de internet.

CenturyLink FAX: 402-998-7341P.O. Box 2738 Customer Service: 888-833-9522 Omaha, NE 68103-2738 Email: [email protected]

ATTACHMENT G



Page 2 of 6

FCC FORM 5629


¿Cuál es tu nombre legal completo? El nombre que usas en documentos oficiales, como tu tarjeta de Seguro Social o identificación estatal. No uses un apodo.

¿Cuál es tu número de teléfono (si tienes uno)?

Nombre

2. Tu informaciónTodos los campos son obligatorios a menos que se indique. Use solo letras mayÚsculas y tinta negra para llenar a esta forma.

* Las tierras tribales incluyen cualquier reserva, pueblo, o colonia reconocida federalmente como tribu indígena, incluyendo reservas anteriores en Oklahoma; regiones nativas de Alaska establecidas de acuerdo con la Alaska Native Claims Settlement Act (85 Stat. 688); asignaciones indias; Hawaiian Home Lands—áreas mantenidas en fideicomiso para los Hawaianos nativos por el estado de Hawaii, de acuerdo con la Hawaiian Homes Commission Act, 1920 July 9, 1921, 42 Stat. 108, et. seq., en su forma modificada; y cualquier terreno designado como tal por la Comisión para los propósitos de esta parte de acuerdo con el proceso de designación en las reglas de Lifeline de la FCC.

¿Cuál es tu fecha de nacimiento?

Mes Día Año

¿Cuál es tu dirección de correo electrónico (si tienes una)?

¿Cuál es la mejor manera de contactarte? correo electrónico teléfono mensaje de texto correo

¿Cuáles son los últimos 4 números de tu Número de Seguro Social (SSN)?

¿Si no tienes un SSN, cuál es tu Número de IdentificaciÓn Tribal?

Segundo Nombre (opcional) Sufijo (opcional)

Apellido

¿Cual es la dirección de tu casa? (La dirección donde vas a recibir el servicio. No uses un P.O. Box)

Número y Nombre de Calle

Ciudad Código PostalEstado

Dpto., Unidad, Otro

¿Es una dirección temporal? Sí No Marca esta caja si vives en tierras Tribales*

¿Cuál es tu dirección postal? (Solo llena esta sección si no es la misma que tu casa)



Dpto., Unidad, Otro

ATTACHMENT G



Page 3 of 6

FCC FORM 5629


Nombre


Apellido

2. Tu información (continuado)Solo llena a esta sección si estas aplicando a través de un hijo o dependiente.

Marca esta caja si estas calificando a través de tu hijo o un dependiente en tu hogar. Si es así, contesta a las siguientes preguntas:

¿Cuál es el nombre legal completo de tu hijo o dependiente?

¿Cuál es su fecha de nacimiento?

¿Cuáles son los últimos 4 números del Número de Seguro Social (SSN) de tu hijo o dependiente?

¿Si no tiene un SSN, cuál es su Número de IdentificaciÓn Tribal?

Marca esta caja si vive en tierras Tribales

Mes Día Año

ATTACHMENT G



Page 4 of 6

FCC FORM 5629


Marca a todos los programas que tu o alguien en tu hogar tiene:

Programa de Asistencia para Nutrición Suplementaria (SNAP) (Estampillas para Alimentos)

Seguridad de Ingreso Suplementario (SSI)

Medicaid

Asistencia Federal para la Vivienda Pública (FPHA)

Pensión de Veteranos y Beneficios para Sobrevivientes

Programas Específicos Para Tribus

Asistencia General del Bureau of Indian Affairs (BIA)

Asistencia Temporal para Familias Necesitadas de Tribus (TANF Tribal)

Programa de Distribución de Alimentos en Reservaciones Indígenas (FDPIR)

Head Start (solo los hogares que cumplen con el estándar de ingresos)

Califica a través de un programa de gobierno:

OCalifica a través de tus ingresos: (Sólo llena esta forma si no calificas a través de un programa de gobierno.)

3. Califica para LifelineLlena esta sección para demostrar que tú, tu dependiente, o alguien de tu hogar califica para Lifeline.

Puedes calificar a través de algunos programas de asistencia de gobierno o a través de tus ingresos (no necesitas calificar a través de los dos).

¿Incluyéndote a ti, cuántas personas viven en tu hogar? (marca a una caja)

¿Tus ingresos son iguales o menos que la cantidad enumerada para tu estado y tamaño del hogar?(Solo marca sí o no a lado de la cantidad que le corresponde al tamaño de tu hogar)

Todos los 48 estados y DC (no Alaska y Hawái)

Alaska Hawái

1 $16,389 $20,493 $18,846 Sí No

2 $22,221 $27,783 $25,555.50 Sí No

3 $28,053 $35,073 $32,265 Sí No

4 $33,885 $42,363 $38,974.50 Sí No

5 $39,717 $49,653 $45,684 Sí No

6 $45,549 $56,943 $52,393.50 Sí No

7 $51,381 $64,233 $59,103 Sí No

8 $57,213 $71,523 $65,812.50 Sí No

Si son más de 8, agrega esta cantidad por cada persona adicional:

Agrega $5,832

Agrega $7,290

Agrega $6,709.50 Sí No

135% de las Guías Federales de Pobreza 2018 *Las Guías de Pobreza Federal se actualizan típicamente a fines de enero.

ATTACHMENT G



Page 5 of 6

FCC FORM 5629


Firma Fecha de hoy

4. AcuerdoAcepto, bajo pena de perjurio, las siguientes declaraciones:

Iníciala junto a cada declaración.

¿Cuál es el nombre legal completo del agente? El nombre que usa en los documentos oficiales, como su tarjeta de Seguro Social o identificación estatal. No uses un apodo.

¿Cuál es el número de identificación de USAC del agente?

Nombre Apellido Segundo Nombre (opcional)

5. Información del AgenteResponde sólo si una persona de ventas entrega esta forma.

¿Cuál es la fecha de nacimiento del agente?

Mes Día Año

Sufijo (opcional)

Iniciales

Actualmente, yo (o mi dependiente o otra persona en mi hogar) recibo beneficios del programa de gobierno enumerada en esta forma o los ingresos anuales de mi hogar son al nivel o menos del 135% de las Guías Federales de Pobreza (la cantidad enumerada en la tabla de Guías Federales de Pobreza en esta forma).

Iniciales

Estoy de acuerdo en que si me mudo, le daré a mi proveedor de servicios mi nueva dirección dentro de 30 días.

Iniciales

Entiendo que necesito informar a mi proveedor de servicios dentro de 30 días si ya no califico para Lifeline, incluyendo: 1) Yo, o la persona de mi hogar que califica, ya no califico a través de un programa de gobierno

o de ingresos. 2) Yo o alguien en mi hogar recibe más de un beneficio de Lifeline (incluyendo, más de un

servicio de internet de banda ancha Lifeline, más de un servicio telefónico Lifeline, o los dos servicios telefónico Lifeline e internet de banda ancha Lifeline).

Iniciales

Sé que mi hogar sólo puede obtener un beneficio de Lifeline y, al mejor de mi conocimiento, mi familia no recibe más de un beneficio de Lifeline.

Iniciales

Estoy de acuerdo en que mi proveedor de servicios pueda darle al administrador del Programa de Lifeline toda la información que estoy dando en esta forma. Entiendo que esta información está destinada a ayudar a ejercer al Programa de Lifeline y que si no permito que lo entreguen al administrador, no podré obtener los beneficios de Lifeline.

Iniciales

Todas las respuestas y acuerdos que he escrito en esta forma son verdaderos y correctos al mejor de mi conocimiento.

Iniciales

Sé que voluntariamente dar información falsa o fraudulenta para obtener beneficios del Programa de Lifeline es castigable por la ley y puede resultar en multas, tiempo de cárcel, la cancelación de mi suscripción, o exclusión del programa.

Iniciales

Es posible que en cualquier momento, mi proveedor de servicios tenga que comprobar si todavía califico. Si necesito recertificar (renovar) a mi beneficio de Lifeline, entiendo que tengo que responder antes de la fecha límite o que me eliminaran del Programa de Lifeline y mi beneficio Lifeline parara.

Iniciales

Yo fui sincero cuando indique si vivo o no vivo en tierras tribales, como se define en la sección 2 de esta forma.

Doy mi consentimiento para que USAC me contacte en mi número de teléfono de Lifeline para recibir recordatorios y actualizaciones importantes sobre mi servicio de Lifeline. Se pueden aplicar tarifas de mensajes y datos. Envié STOP por mensaje de texto para detener a los mensajes.

ATTACHMENT G



Page 6 of 6

FCC FORM 5629


Notificación NOTIFICACIÓN DE LA LEY DE REDUCCIÓN DE TRÁMITES: la sección 54.410 de las normas de la Comisión Federal de Comunicaciones (Federal Communications Commission, FCC) exige que todos los suscriptores de Lifeline demuestren su elegibilidad para recibir los servicios de Lifeline. Esta recopilación de información se deriva de la autoridad de la Comisión según la Sección 254 de la Ley de Comunicaciones de 1934, en su forma enmendada, Título 47 del Código de los Estados Unidos (United States Code, U.S.C.) sección 254. Usando esta autoridad, la FCC designó a la Compañía Administrativa de Servicio Universal (Universal Service Administrative Company, USAC) como la administradora permanente de Lifeline. La FCC publicó las normas que detallan cómo los consumidores pueden calificar para los servicios de Lifeline y cuáles servicios pueden recibir (título 47 del Código de Regulaciones Federales [Code of Federal Regulations, CFR], sección 54.400 et seq.). La USAC utilizará la información proporcionada en respuesta a esta recopilación de información para verificar la elegibilidad del solicitante para los servicios de Lifeline.

Estimamos que cada respuesta a esta recopilación de información tomará, en promedio, entre 0.25 y 0.75 horas. Nuestra estimación incluye el tiempo para leer las preguntas, examinar los registros existentes, recopilar la información necesaria y en efecto completar y revisar el formulario o la respuesta. Si tiene algún comentario sobre esta estimación, o sobre cómo podemos mejorar la recopilación y reducir la carga que representa para usted, escriba a la Comisión Federal de Comunicaciones, a la Oficina del Director General de la División de Evaluación del Desempeño y Gestión de Registros (Office of Managing Director-Performance Evaluation and Records Management, OMD-PERM), Proyecto de Reducción de Trámites (3060-0819), Washington, D.C. 20554. También aceptaremos sus comentarios a través de Internet si los envía a [email protected]. NO ENVÍE Las formas LLENOS DE RECOPILACIÓN DE INFORMACIÓN A ESTA DIRECCIÓN.

Recuerde – no es necesario que responda a una recopilación de información patrocinada por el gobierno federal y el gobierno no puede realizar ni patrocinar esta recopilación, a menos que muestre un número de control vigente de la Oficina de Administración y Presupuesto (Office of Management and Budget, OMB). A esta recopilación se le asignó el número de control de la OMB 3060-0819.

La Comisión está autorizada, de acuerdo con la Ley de Comunicaciones de 1934, en su forma enmendada, a recopilar la información que solicitamos en esta forma. Si creemos que puede haber una violación o posible violación de un estatuto o reglamento, norma u orden de la Comisión, su respuesta podría remitirse a la agencia federal, estatal o local responsable de investigar, enjuiciar, hacer cumplir o implementar el estatuto, norma, regulación u orden.

Si no proporciona la información que solicitamos en esta forma, usted no será elegible para recibir los servicios de Lifeline, de acuerdo con las normas del programa Lifeline, título 47 del C.F.R., sección 54.400-54.423.

La Ley de Reducción de Trámites de 1995, P.L. No. 104-13, título 44 del U.S.C., sección 3501, et seq, exige la notificación que precede

DECLARACIÓN DE LA LEY DE PRIVACIDAD: la Ley de Privacidad es una ley que exige que la Comisión Federal de Comunicaciones (FCC) y la Compañía Administrativa de Servicio Universal (USAC) expliquen por qué le pedimos a las personas información personal y lo que vamos a hacer con esta información una vez que la recopilemos.

Autoridad: la Sección 254 de la Ley de Comunicaciones (título 47 del U.S.C., sección 254), en su forma enmendada, autoriza a la FCC a operar el programa Lifeline. Usando esta autoridad, la FCC designó a la USAC como la administradora permanente de Lifeline. La FCC publicó las normas que detallan cómo los consumidores pueden calificar para los servicios de Lifeline y cuáles servicios pueden recibir (título 47 del CFR, sección 54.400 et seq.).

Propósito: recopilamos esta información personal para que podamos verificar que usted califica para el programa Lifeline y para que podamos brindarle de manera eficiente los servicios de Lifeline. Accedemos, mantenemos y utilizamos su información personal de la manera descrita en la Notificación del Sistema de Registros (System of Records Notice, SORN) de Lifeline, FCC/WCB-1, que publicamos en 82 Fed. Reg. 38686 (15 de agosto de 2017).

Usos de rutina: podemos compartir la información personal que ingrese en esta forma con otras partes para fines específicos, tales como: con contratistas que nos ayudan a operar el programa Lifeline; con otras agencias gubernamentales federales y estatales que nos ayudan a determinar su elegibilidad para Lifeline; con las compañías de telecomunicaciones que le brindan el servicio de Lifeline; y con fuerzas policiales y otros funcionarios que investigan posibles violaciones de las normas de Lifeline.

Una lista completa de las formas en que podemos usar su información se publica en la SORN de Lifeline descrita en el párrafo “Propósito” de esta declaración.

Divulgación: usted no está obligado a proporcionar la información que solicitamos en esta forma, pero si no lo hace, no será elegible para recibir los servicios de Lifeline según las normas del programa Lifeline, título 47 del C.F.R., sección 54.400-54.423.

ATTACHMENT G


Programa de Lifeline: Hoja de Hogar

Page 1 of 3

FCC FORM 5631


Uso de esta hojaUsa esta hoja si alguien en tu dirección obtiene Lifeline. Tus respuestas a estas preguntas te ayudarán a saber si hay más de un hogar en tu dirección.

¿Qué es un hogar?Un hogar es un grupo de personas que viven juntas y comparten ingresos y gastos (aunque no sean parientes).

Ejemplos de un hogar: • Una pareja casada que convive es un hogar. Deben compartir un beneficio de Lifeline. • Un padre / guardián y un niño que viven juntos son un hogar. Deben compartir un

beneficio de Lifeline. • Un adulto que vive con amigos o familiares que lo apoyan financieramente es un hogar.

Deben compartir un beneficio de Lifeline.

Ejemplos de más de un hogar: • 4 compañeros de habitación que viven juntos pero no comparten dinero son 4 hogares.

Pueden tener un beneficio de Lifeline cada uno, 4 en total. • 30 personas de la tercera edad que viven en una vivienda asistida son 30 hogares.

Pueden tener un beneficio de Lifeline cada uno, 30 en total.

Gastos de un hogarUn hogar comparte gastos. Los gastos del hogar incluyen, pero no se limitan a, alimentos, gastos de salud, y el costo de alquilar o pagar una hipoteca en tu lugar de residencia y servicios públicos.

IngresosLos hogares comparten ingresos. Los ingresos incluyen salario, beneficios de asistencia pública, pagos de seguridad social, pensiones, compensación de desempleo, beneficios de veteranos, herencias, pensión alimenticia, pagos de manutención de hijos, beneficios de compensación de trabajadores, regalos, y ganancias de lotería.

Sobre LifelineLifeline es un beneficio federal que reduce el costo mensual de servicio telefónico o de internet (no ambos). Sólo se permite un beneficio de Lifeline por hogar, no por persona.

ATTACHMENT G



Page 2 of 3

FCC FORM 5631


No calificas para Lifeline porque alguien en tu hogar ya recibe el beneficio. Sólo se permite un beneficio de Lifeline por hogar, no por persona.

Marca esta caja

Puedes aplicar para Lifeline. Vives en una casa que no tiene Lifeline todavía. Por favor iníciala a la línea B , y escribe a tu firma y la fecha.

Marca esta caja

¿Puedes Aplicar?Sigue este árbol de decisión para confirmar si calificas para el Programa de Lifeline.

Puedes aplicar para Lifeline. Tú vives en una dirección con más de un hogar y tu hogar no recibe Lifeline todavía. Por favor iníciala a las líneas A y B , y escribe a tu firma y la fecha.

Marca esta caja

2. ¿Él o ella tiene Lifeline? Sí No

1. ¿Vives con otro adulto?Los adultos son personas mayores de 18 años o menores emancipados. Esto puede incluir un esposo o esposa, pareja doméstica, padre, hijo adulto o hija adulta, adulto en tu familia, compañero de cuarto adulto, etc.

Sí No

3. ¿Compartes dinero (ingresos y gastos) con ella o él?Esto puede ser el costo de tus facturas, alimentos, o otro, y tus ingresos. Si está casado, debes de marcar sí para esta pregunta.

Sí No

En caso afirmativo, responde a la pregunta 3

En caso afirmativo, responde a la pregunta 2

¿Cuál es tu nombre legal completo? El nombre que usas en documentos oficiales, como tu tarjeta de Seguro Social o identificación estatal. No uses un apodo.

Nombre


Apellido

¿Cual es la dirección de tu casa? (La dirección donde vas a recibir el servicio. No uses un P.O. Box)



Dpto., Unidad, etc.

ATTACHMENT G



Page 3 of 3

FCC FORM 5631


Notificación NOTICE: NOTIFICACIÓN DE LA LEY DE REDUCCIÓN DE TRÁMITES: la sección 54.410 de las normas de la Comisión Federal de Comunicaciones (Federal Communications Commission, FCC) exige que todos los suscriptores de Lifeline demuestren su elegibilidad para recibir los servicios de Lifeline. Si más de una persona en la misma dirección solicita el servicio de Lifeline, todos los solicitantes deben presentar una Hoja de trabajo del grupo familiar. Esta recopilación de información se deriva de la autoridad de la Comisión según la Sección 254 de la Ley de Comunicaciones de 1934, en su forma enmendada, título 47 del Código de los Estados Unidos (United States Code, U.S.C.) sección 254. Usando esta autoridad, la FCC designó a la Compañía Administrativa de Servicio Universal (Universal Service Administrative Company, USAC) como la administradora permanente de Lifeline. La FCC publicó las normas que detallan cómo los consumidores pueden calificar para los servicios de Lifeline y cuáles servicios pueden recibir (título 47 del Código de Regulaciones Federales [Code of Federal Regulations, CFR], sección 54.400 et seq.). La USAC utilizará la información proporcionada en respuesta a esta recopilación de información para verificar la elegibilidad del solicitante para los servicios de Lifeline.

Estimamos que cada respuesta a esta recopilación de información tomará, en promedio, 0.25 horas. Nuestra estimación incluye el tiempo para leer y completar el formulario y revisar el formulario o la respuesta. Si tiene algún comentario sobre esta estimación, o sobre cómo podemos mejorar la recopilación y reducir la carga que representa para usted, escriba a la Comisión Federal de Comunicaciones, a la Oficina del Director General de la División de Evaluación del Desempeño y Gestión de Registros (Office of Managing Director-Performance Evaluation and Records Management, OMD-PERM), Proyecto de Reducción de Trámites (3060-0819), Washington, D.C. 20554. También aceptaremos sus comentarios a través de Internet si los envía a [email protected]. NO ENVÍE LOS FORMULARIOS LLENOS DE RECOPILACIÓN DE INFORMACIÓN A ESTA DIRECCIÓN.

Recuerde – no es necesario que responda a una recopilación de información patrocinada por el gobierno federal y el gobierno no puede realizar ni patrocinar esta recopilación, a menos que muestre un número de control vigente de la Oficina de Administración y Presupuesto (Office of Management and Budget, OMB). A esta recopilación se le asignó el número de control de la OMB 3060-0819.

La Comisión está autorizada, de acuerdo con la Ley de Comunicaciones de 1934, en su forma enmendada, a recopilar la información que solicitamos en este formulario. Utilizaremos la información que proporcione para determinar su elegibilidad para los servicios de Lifeline. Si creemos que puede haber una violación o posible violación de un estatuto o reglamento, norma u orden de la Comisión, su formulario podría remitirse a la agencia federal, estatal o local responsable de investigar, enjuiciar, hacer cumplir o implementar el estatuto, norma, regulación u orden. En ciertos casos, la información en su formulario puede divulgarse al Departamento de Justicia, a un tribunal u otro órgano adjudicativo cuando (a) la Comisión, (b) cualquier empleado de la Comisión o (c) el gobierno de Estados Unidos sea parte en un proceso judicial ante el organismo o tenga un interés en el proceso judicial.

Si no proporciona la información que solicitamos en este formulario, usted no será elegible para recibir los servicios de Lifeline, de acuerdo con las normas del programa Lifeline, título 47 del C.F.R., sección 54.400-54.423.

La Ley de Reducción de Trámites de 1995, P.L. No. 104-13, título 44 del U.S.C., sección 3501, et seq, exige la notificación que precede.

DECLARACIÓN DE LA LEY DE PRIVACIDAD: la Ley de Privacidad es una ley que exige que la Comisión Federal de Comunicaciones (FCC) y la Compañía Administrativa de Servicio Universal (USAC) expliquen por qué le pedimos a las personas información personal y lo que vamos a hacer con esta información una vez que la recopilemos.

Autoridad: la Sección 254 de la Ley de Comunicaciones (título 47 del U.S.C., sección 254), en su forma enmendada, autoriza a la FCC a operar el programa Lifeline. Usando esta autoridad, la FCC designó a la USAC como la administradora permanente de Lifeline La FCC publicó las normas que detallan cómo los consumidores pueden calificar para los servicios de Lifeline y cuáles servicios pueden recibir (título 47 del CFR, sección 54.400 et seq.).

Propósito: recopilamos esta información personal para que podamos verificar que usted califica para el programa Lifeline y para que podamos brindarle de manera eficiente los servicios de Lifeline. Accedemos, mantenemos y utilizamos su información personal de la manera descrita en la Notificación del Sistema de Registros (System of Records Notice, SORN) de Lifeline, FCC/WCB-1, que publicamos en 82 Fed. Reg. 38686 (15 de agosto de 2017).

Usos de rutina: podemos compartir la información personal que ingrese en este formulario con otras partes para fines específicos, tales como: con contratistas que nos ayudan a operar el programa Lifeline; con otras agencias gubernamentales federales y estatales que nos ayudan a determinar su elegibilidad para Lifeline; con las compañías de telecomunicaciones que le brindan el servicio de Lifeline; y con fuerzas policiales y otros funcionarios que investigan posibles violaciones de las normas de Lifeline.

Una lista completa de las formas en que podemos usar su información se publica en la SORN de Lifeline descrita en el párrafo “Propósito” de esta declaración.

Divulgación: usted no está obligado a proporcionar la información que solicitamos en este formulario, pero si no lo hace, no será elegible para recibir los servicios de Lifeline según las normas del programa Lifeline, título 47 del C.F.R, sección 54.400-54.423.

Iniciales A Vivo en una dirección con más de un hogar.

Iniciales

B Entiendo que el límite de un solo hogar es una regla de La Comisión Federal de Comunicaciones (Federal Communications Commission, FCC por sus siglas en inglés) y que perderé a mi beneficio de Lifeline si rompo esta regla.

AcuerdoIníciala el siguiente acuerdo y escribe a tu firma y la fecha. Entrega esta hoja a tu proveedor de servicios con la Programa de Lifeline Forma de Aplicación.

Firma Fecha de Hoy

Doy mi consentimiento para que USAC me contacte en mi número de teléfono de Lifeline para recibir recordatorios y actualizaciones importantes sobre mi servicio de Lifeline. Se pueden aplicar tarifas de mensajes y datos. Envié STOP por mensaje de texto para detener a los mensajes.

ATTACHMENT G

Documents

ATTACHMENT G IMPORTANT NEWS FROM CENTURYLINK … · CenturyLink will provide the block, where feasible, at no charge to you. Telecommunications Relay Service . Dial 7-1-1 or Special