Florida

Low-Income Assistance Plan

Self Certification Form

    
   
This certification can be completed on-line! Go to www.americandialtone.com and click the link “Florida on-line Certification” in the right hand column.
Billing Name             ___________________________________       Date__________
Service Address       ____________________________________________________
City     ___________________________           State ______                   Zip _________
Phone Number        (_____)__________            Social Sec # (last 4 digits req'd ____________
   

I hereby certify that I participate in the following public assistance program(s):(Check all that apply)

   (   )    Medicaid (   )     Temporary Assistance to Needy Families / AFDC (TANF)
   (   )    Food Stamps (   )     Federal Public Housing Assistance or Section 8
   (   )    State Means Test (OPC Cert) (   )     Low-Income Home Energy Assistance Program (LIHEAP)
   (   )    School Free Lunch Program (   )     Supplemental Security Income (SSI)
 

I certify, under penalty of perjury, that I am a current recipient of the above program(s) and will notify my local telephone company when I am no longer participating in at least one of the above-designated program(s). I authorize my local telephone company or it’s duly appointed representative to access any records required to verify these statements to confirm my continued participation in the above program(s). I authorize representatives of the above programs to discuss with and/or provide copies to my local telephone company, if requested by the company, to verify my participation in the above program(s) and my eligibility for this program.

 

___________________________________________                  ___________________

Applicant’s signature                                                                                Date

 

This certification is good for up to one year from the date of signing. This certification must be updated annually to avoid program termination.

 

*If you are at or below 135% of the poverty level, but are not currently receiving benefits from one of the listed programs, you may be able to qualify by contacting the Office of Public Counsel in Tallahassee at 1-800-540-7039.
   

Please mail this self-certification to:

 

 

 

Or Fax to:                                    		 American Dial Tone Assistance Program
P.O. Box 2203
Dunedin, FL 34697-2203

(727)669-9451 Pinellas, 1-866-700-0434 toll free

--- Internal Use Only ---

Date Ordered _______________     PON# ______________ By_________