PERJURY STATEMENTS

1. I participate in the above designated qualifying program or have income at or below the level specified above and will provide documentation of eligibility if required to do so.
2. I understand that I must notify Q Link Wireless within 30 days if I no longer participate in the qualifying program or no longer meet the income criteria, if I or another member of my household obtains Lifeline service from another carrier, or, for any other reason, I no longer qualify for Lifeline. I acknowledge that I may not have multiple Lifeline Program benefits with the same or different providers.
3. I understand I may be required to recertify my continued eligibility for Lifeline at any time, and failure to do so will result in termination of my Lifeline benefits. I am required to use my Q Link phone at least once every 60 days, or my service will be suspended, subject to a 30 day period which I may use the service or contact Q Link Wireless to confirm that I want to continue receiving their service.
4. If I change my address, I will provide my new address to Q Link Wireless within 30 days. If my address is temporary, I understand that I must verify my address with Q Link Wireless every 90 days.
5. My household will receive only one Lifeline benefit and to the best of my knowledge, my household and/or spouse does not already receive a Lifeline service. I do not share living expenses and income with any other adult who currently resides at my address and is receiving Lifeline service. Violation of the one-per-household requirement would constitute a violation of the Commission's rules and would result in de-enrollment from the program, and potentially, prosecution by the United States government. I also understand that this is a non-transferable service.
6. The information contained in this application is true and accurate to the best of my knowledge, and I acknowledge that providing false or fraudulent information to obtain Lifeline benefits is punishable by law. I understand that the date of my application shall be based upon when I became eligible to receive service at provider's sole discretion.
7. I authorize Q Link Wireless or its duly appointed representative to: (1) access any records to verify my statements herein; (2) to confirm my continued eligibility for Lifeline; (3) to update my address to a proper format; (4) to provide any and all of the information related to my account including but not limited to my name and address to the Universal Service Administrative Company (USAC) and/or its agents for the purpose of verifying that I only receive one Lifeline benefit; and (5) authorize social service agency representatives to discuss with and/or provide information to Q Link Wireless verifying my participation in benefit program(s) that qualifies me for Lifeline assistance. If USAC identifies I am receiving more than one Lifeline subsidy, all carriers involved may be notified so that I may select one service and be de-enrolled from the other. I agree to transfer my existing Lifeline Program benefit to Q Link Wireless which will result in changing my current Lifeline phone number, service and provider. I also authorize Q Link Wireless to de-enroll my existing service and choose Q Link Wireless as my sole Lifeline provider.