20130319Exhibit 1 to Second Amendment.pdf

PECE' From: Shoemaker, Adam [[e-mail] ]
Sent:
To:
Tuesday, March 19, 2013 11:14 AM
Jean Jewell
*
Cc:
Subject
Grace Seaman
Nexus Communications - Supplement to Second Amendment of i4Denation
as an ETC UTtLI I 1t$
Attachments: Nexus 2nd Amendment Exhibit I .pdf
i/cr-i-/1-OI
Dear Ms. Jewell,
On behalf of Nexus Communications, Inc., please find attached Exhibit 1 to the Second Amendment to the Application of
Nexus Communications, Inc. for Designation as an Eligible Telecommunications Carrier for Low Income Support Only.
This Exhibit was inadvertently not included with the Second Amendment, which was filed on March 15, 2013.
Please do not hesitate to contact me if you have any questions.
Respectfully submitted,
Adam Shoemaker
Adam Shoemaker I Davis Wright Tremaine LLP
1919 Pennsylvania Avenue NW, Suite 800 I Washington, DC 20006-3401
Tel: [phone] I Fax: [phone]
Email:adamshoemakerVdwt.com I Website:www.dwt.com
Anchorage I Bellevue I Los Angeles I New York I Portland I San Francisco I Seattle I Shanghai I Washington, D.C.
The DWT Lifeline Team provides advice to top-tier and emerging Lifeline providers (wireless and wireline).
For our coverage of developments in the Lifeline industry, please visit: http://www.lifelinelaw.com/
RE.cEivEr.
2013MARI9 AMtI:O
WcHt
..TILlES C..)MMISSi
Exhibit 1
Lifeline Applications
Nexus Communications, Inc. d/b/a
_ 01 Fax to: 1-877-870-9333 Email to: [e-mail] or
Mail to: ReachOut Wireless, P0 Box 247168, Columbus, OH 43224-7168
125 FREE Rollover Minutes - 250 FREE Non-Rollover Minutes LIFELINE APPLICATION
I certify that I participate in one of the following programs (check one):
- Food Stamps (SNAP) - Medicaid
- Federal Public Housing Assistance (Section 8)
-Temporary Assistance to Needy Families (TANF)
- National School Lunch Free Lunch Program
-Supplemental Social Security (SSI)
Low-Income Home Energy Assistance Program (LIHEAP) If you wish to qualify based on income, a different form is required.
You must provide documentation demonstrating your current participation in the program checked above.
Last Name: First Name: Middle Initial:
Last 4 digits of Soc. Security #: Date of Birth:
Residential Address: Apt. ______ City: State:_ Zip:
(no P.O. Box for res. address) This is my (check one): Permanent Address - Temporary Address
If you move, you must update your residential address with ReachOut Wireless within 30 days
Billing Address (if different): Apt. _______ City: State: - Zip:
I certify that:
- I acknowledge that Lifeline is a government assistance program and that willfully making false statements to obtain the benefit can result
in fines, imprisonment, de-enrollment or being barred from the program.
- I acknowledge that only Lifeline eligible consumers may enroll in the Lifeline Program.
I acknowledge that only one Lifeline service is available per household, and that, to the best of my knowledge, no other person in my
household Is receiving a Lifeline service. (For purposes of Lifeline, a "household" is any individual or group of individuals who live
together at the same address and share income and expenses.)
- I acknowledge that a household is not permitted to receive Lifeline benefits from multiple providers and that violation of this limitation
constitutes a violation of the rules of the Federal Communications Commission and will result in de-enrollment from the Lifeline program.
If I am participating in another Lifeline program at the time I apply for ReachOut Wireless Lifeline service, I agree to cancel that Lifeline
service with any other provider.
- I acknowledge that Lifeline is non-transferable and that I may not transfer my benefit to any other person.
I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law.
I will notify ReachOut Wireless within 30 days if for any reason I no longer satisfy the criteria for receiving Lifeline services, such as no
longer participating in any of qualifying program, or if I or a member of my household receives another Lifeline benefit.
-

I acknowledge that I may be required to re-certify to my continued eligibility for Lifeline at any time, and that my failure to re-certify will
result in de-enrollment and termination of my Lifeline benefits.
If I move to a new address, I will provide the new address to ReachOut Wireless within 30 days.
- If I provided a temporary address, I will be required to verify my temporary address every 90 days. If I do not provide verification within
30 days, I will be de-enrolled from the Lifeline program.
I authorize Reachout Wireless to access any state or federal governmental records or database required to verify my statements herein
and to confirm my continued eligibility for Lifeline and authorize social service agency representatives to discuss with and/or provide
information to ReachOut Wireless verifying my participation in programs that qualify me for Lifeline. I also authorize ReachOut Wireless
to release any records required for the administration of ReachOut Wireless's Lifeline program, including to the Universal Service
Administrative Company (USAC), to be used in a Lifeline Program Database. I understand that the records are required to ensure the
proper administration of the Lifeline program and that failure to provide consent will result in the applicant being denied the Lifeline
service.
- I certify penalty of perjury that the information contained in this certification is true and correct to the best of my knowledge.
Applicant's Signature: Date:
Customer Service 1 - 877 - 870 - 9444
www.reachoutmobile.com
Nexus Communications, Inc. d/b/a
ROO ftl it
LIFELINE APPLICATION
Fax to: 1 -877-870-9333 Email to: [e-mail] or
Mail to: ReachOut Wireless, P0 Box 247168, Columbus, OH 432247168
125 FREE Rollover Minutes 250 FREE Non-Rollover Minutes
that my household income is at or below 15Yo 01 the l-ecleral I-'overtv uioeiines as inaicatea oeiow:
Eligibility for Lifeline may apply if your household income is at or below
135% of the Federal Poverty Guidelines for a household of that size.
Indicate which income range applies to you in the chart. You must
provide proof of eligibility based on income, which can include:
• Last year's federal or state tax return
• Current income statement from an employer or paycheck stub
(must cover 3 consecutive months within the previous 12 months)
• A Social Security statement of benefits
• A retirement/pension statement of benefits
• An Unemployment/Workers' Compensation statement of benefit
• Federal notice letter of participation in General Assistance
• Divorce decree, child support award or other official document
containing income information
Persons in
Household Annual Income Monthly
Income
1 $15,080 $1,257
2 $20,426 $1,702
3 $25,772 $2,148
4 $31,118 $2,593
5 $36,464 $3,039
6 $41,810 $3,484
7 $47,156 $3,930
8 $52,502 $4,375
For each add'I
person, add: $5,346
-
$446
Last Name: First Name: Middle Initial:
Last 4 digits of Soc. Security U: Date of Birth:
Residential Address: Apt. ______ City: _________ State: - Zip:
(no P.O. Box for res. address) This is my (check one): _____ Permanent Address_ Temporary Address
If you move, you must update your residential address with ReachOut Wireless within 30 days.
Billing Address (if different): Apt. City: __________ State: - Zip: -
I certify that:
I acknowledge that Lifeline is a government assistance program and that willfully making false statements to obtain the benefit can result
in fines, imprisonment, de-enrollment or being barred from the program.
- I acknowledge that only Lifeline eligible consumers may enroll in the Lifeline Program.
- I acknowledge that only one Lifeline service is available per household, and that, to the best of my knowledge, no other person in my
household is receiving a Lifeline service. (For purposes of Lifeline, a "household" is any individual or group of individuals who live
together at the same address and share income and expenses.)
- I acknowledge that a household is not permitted to receive Lifeline benefits from multiple providers and that violation of this limitation
constitutes a violation of the rules of the Federal Communications Commission and will result in de-enrollment from the Lifeline program.
If I am participating in another Lifeline program at the time I apply for ReachOut Wireless Lifeline service, I agree to cancel that Lifeline
service with any other provider.
- I acknowledge that Lifeline is non-transferable and that I may not transfer my benefit to any other person.
- I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law.
- I will notify ReachOut Wireless within 30 days if for any reason I no longer satisfy the criteria for receiving Lifeline services, such as no
longer meeting the income levels, or if I or a member of my household receives another Lifeline benefit.
- I acknowledge that I may be required to re-certify to my continued eligibility for Lifeline at anytime, and that my failure to re-certify will
result in de-enrollment and termination of my Lifeline benefits.
If I move to a new address, I will provide the new address to ReachOut Wireless within 30 days.
- If I provided a temporary address, I will be required to verify my temporary address every 90 days. If I do not provide verification within
30 days, I will be de-enrolled from the Lifeline program.
- I authorize Reachout Wireless to access any governmental state or federal records or database located anywhere required to verify my
statements herein and to confirm my continued eligibility for Lifeline and authorize social service agency representatives to discuss with
and/or provide information to ReachOut Wireless verifying my participation in programs that qualify me for Lifeline. I also authorize
ReachOut Wireless to release any records required for the administration of ReachOut Wireless's Lifeline program, including to the
Universal Service Administrative Company (USAC) to be used in a Lifeline Program Database. I understand that the records are required
to ensure the proper administration of the Lifeline program and that failure to provide consent will result in the applicant being denied
the Lifeline service.
- I certify penalty of perjury that the information contained in this certification is true and correct to the best of my knowledge.
Applicant's Signature: Date
Customer Service 1 - 877 - 870 - 9444
www.reachoutmobile.com