TTY      TTY with LVD      TTY with Braille         
HCO/VCO phone      Amplified Phone 

2. I am receiving assistance from one or more of the following programs (if not receiving assistance skip to part b)
a.

Aid to Families with Dependent Children
Emergency Work Program
Food Stamps
General Assistance
Home Energy Assistance Target Program and/or Lifeline (Phone)
Medical Assistance
Refugee Assistance
Supplemental Security Income or Social Security Disability Income (SSI) or (SSDI)

b. I am not receiving assistance but my income qualifies:

Total Household Income is /month

Total Number of Persons Living in Household

3. Someone in my household (including myself) already owns an assistive telecommunications device that functions as it should.

YES                                 NO

Please read the following statements.  If you are in agreement, please fill out the information below.  By supplying this information and submitting the form you agree that the information submitted on this form is true and correct to the best of your knowledge.

A. If I stop receiving assistance and/or my monthly income increases, I will IMMEDIATELY notify the Public Service Commission.

I Agree                             I Disagree

B. I will return the borrowed device to the Public Service Commission if, and when, I no longer reside in the state of Utah.

I Agree                             I Disagree

C. I understand that if I provide false information, I will have to return all assistive devices to the Public Service Commission IMMEDIATELY.

I Agree                              I Disagree

D. I understand that it is my responsibility to obtain telephone service and I assume responsibility for payment of all associated fees and charges.

I Agree                              I Disagree

PLEASE PROVIDE THE FOLLOWING INFORMATION
(you must be 18 years of age)

NAME
ADDRESS
HOME PHONE NUMBER