Kentucky

Low-Income Assistance Plan

Self Certification Form

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

(Check all that apply)

Be sure to include a copy of the notice of eligibility for each program you checked above.

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.

Please mail this self-certification to:

--- Internal Use Only ---

Date Ordered _______________     PON# ______________ By_________