Transcription of MINNESOTA APPLICATION FORM - LIFELINE …
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MINNESOTA APPLICATION FORM - LIFELINE …
MINNESOTA APPLICATION FORM - LIFELINE assistance PROGRAM Please Read All Instructions Before Completing Please fill in all information as completely as possible. The information on this APPLICATION is strictly confidential and will only be used to assess your eligibility for LIFELINE assistance . Telephone Number or existing Account # First Name Name Address City State Zip Code Social Security Number Date of Birth PLEASE CHECK programs in which you currently participate: Federal Public Housing/Section 8 Supplemental Security Income (SSI) Low Income Home Energy assistance Program (LIHEAP) Supplemental Nutrition assistance Program (SNAP) Formerly Food Stamps Medicaid Temporary assistance for Needy Families (TANF) National School Lunch (Free Program) MINNESOTA Family Investment Program (MFIP) Household Income at or below 135% of the Federal Poverty Level (must provide documentation see reverse side) PLEASE READ AND SIGN THE FOLLOWING: By signing below, I certify under penalty of perjury that 1) the information contained within this APPLICATION is true and correct.
MINNESOTA APPLICATION FORM - LIFELINE ASSISTANCE PROGRAM Please Read All Instructions Before Completing Please fill in all information as completely as possible.
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