OTAP - Online Application

Online Application Form

Oregon Lifeline Program

Oregon Lifeline is a federal and state government program that provides a monthly discount on phone (up to $15.25) or broadband service (up to $19.25) for qualifying low-income Oregon households with participating service providers (see list below).

You may qualify if you receive one of the following benefits.

Supplemental Nutrition Assistance Program (SNAP),
Medicaid,
Supplemental Security Income (SSI),
Veterans or Survivors Pension,
Federal Public Housing Assistance (Section 8),
Total Household Income is at or below 135% of the Federal Poverty Guidelines,

Tribal Specific Programs

Tribal General Assistance,
Tribal Head Start,
Tribal Temporary Assistance for Needy Families (TANF), or
Tribal Food Distribution Program

Questions?

Contact the Oregon Public Utility Commission

1-800-848-4442
1-800-648-3458 (TTY)
1-877-567-1977 (Fax)
puc.rspf@puc.oregon.gov

Phone hours: Monday - Friday, 9am - 4pm

(* indicates required field)

Applicant's Legal Name

(* First)

(Middle)

(* Last)

* Applicant's Social Security #

* Applicant's Date of Birth:

(Format: 123-12-1234)

(Format: 01/01/1975)

* Applicant's Service Provider:

Note: AT&T Mobility offers the Oregon Lifeline discount in select areas. Please call 1-800-377-9450 to find out if AT&T Mobility offers the Oregon Lifeline discount where you live.

Applicant's Home Address:

(* Street)

(* City)
(* State)
(* Zipcode)

* Do you live on federally-recognized tribal lands in Oregon? Yes No

Is this a temporary address? Yes No

Applicant's Mailing Address (if different than above):
(Choose Type)
(Street)
(City)
(State)
(Zipcode)

* Applicant's Phone or Broadband Account Number for Lifeline Discount to be Applied		Contact Phone Number (If Different than Phone Number for Lifeline Discount)
(Format: 123-123-1234)		(Format 123-123-1234)

Note: If the account number has less than 10 digits, zero(s) will automatically be added at the end after you submit the application.

Applicant's Email Address (username@host.domain):

(Format: john.doe@gmail.com)

Please re-enter your Email Address

* How Does the Applicant Qualify for Oregon Lifeline?

Note: Send acceptable documentation to OPUC within 30 days of submitting this application

1-877-567-1977 (Fax)	puc.rspf@puc.oregon.gov	P.O. Box 1088
		Salem, Or 97308-1088

If the applicant qualifies by income, please indicate the total number of household members, including applicant, with whom the applicant shares income and expenses. If applicant is only member of household, please enter 1.

Please completely READ and INITIAL each rule indicating that you understand and agree to comply with the following:

	1. I understand that completing this application does not immediately approve me for the Oregon Lifeline benefit. I will be notified in writing of my application status.


	2. I understand it may take 30-90 days for the company to apply the Oregon Lifeline benefit to my account.


	3. I give the Oregon Public Utility Commission (PUC), the Federal Communication Commission, and the Universal Service Administrative Company authority to obtain or review any required records needed to confirm my statements and to confirm that I qualify for the Oregon Lifeline benefit. I also authorize the company to release any required records for my Oregon Lifeline benefit.


	4. I am head of household and no one else in my household receives landline or wireless Oregon Lifeline service.


	5. I understand that the Oregon Lifeline benefit is only allowed for ONE ACCOUNT PER HOUSEHOLD


	A household is defined as any persons who live together at the same address and share income and expenses.
	6. I understand that if I break or violate the one-per-household rule I will no longer qualify for the Oregon Lifeline benefit.


	7. I agree to let the PUC know within 30 days if:


	I no longer qualify for the Oregon Lifeline benefit
	I receive more than one Oregon Lifeline benefit
	I disconnected service with my company
	Another member of my household is also receiving the Oregon Lifeline benefit
	8. I understand that I have 30 days to notify the PUC if I no longer qualify for the Oregon Lifeline benefit or I may be removed from the program.


	9. I agree to notify the PUC of address changes within 30 days of moving.


	10. I understand that my Oregon Lifeline benefit may not be transfered or given to any other person.


	11. I understand that I may be required to confirm that I still qualify for the Oregon Lifeline benefit at any time and that, if I do not comply, my Oregon Lifeline benefits will stop.


	12. I understand that Oregon Lifeline is a state and federal benefit and willfully making false statements or providing false or fraudulent documents to obtain the benefit is punishable by law and can result in fines, imprisonment, disqualification or being permanently removed from the program.

By submitting this application I certify under penalty of perjury that the information contained in this application is true and correct and that I meet the eligibility criteria for the Oregon Lifeline benefit.