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Table 1.16 Hawaiian Home Lands by Households in Hawai‘i: 2010 
Hawaiian Home Land 
Total 
Households 
Persons In 
Households 
Average 
Household Size 
Persons in 
Group Quarters 
Anahola (Agricultural) 81 257 3.2 0 
Anahola (Residential) 426 1,557 3.7 9 
Hanapëpë 7 25 3.6 0 
Homuÿula-Upper Piÿihonua 2 3 1.5 0 
Honolulu Makai 0 0 0.0 13 
Honomü 3 6 2.0 0 
Hoÿolehua- Päläÿau 352 1,273 3.6 19 
Kahikinui 1 3 3.0 0 
Kalaÿeloa 0 0 0.0 10 
Kalamaÿula 93 300 3.2 0 
Kalaupapa 69 87 1.3 3 
Kaläwahine 94 319 3.4 0 
Kamäÿoa-Puÿuÿeo 7 14 2.0 0 
Kamiloloa- Makakupaÿia 24 85 3.5 0 
Kamoku- Kapulena 15 46 3.1 0 
Kapaÿakea 42 141 3.4 0 
Kaümana 35 111 3.2 0 
Kaupeÿa 326 1,387 4.3 0 
Kawaihae 131 405 3.1 2 
Kealakehe 219 759 3.5 0 
Keÿanae-Wailua 7 17 2.4 0 
Keaukaha 407 1,582 3.9 2 
Kekaha 114 483 4.2 0 
Këökea (Agricultural) 9 24 2.7 0 
Kewalo 51 261 5.1 0 
Lälämilo 22 64 2.9 0 
Länaÿi City 23 85 3.7 0 
Leialiÿi 91 328 3.6 0 
Lualualei 13 58 4.5 0 
Mäÿili 1 6 6.0 317 
Mäkaha Valley 1 4 4.0 0 
Makuÿu 41 113 2.8 0 
Maluöhai 251 1,178 4.7 0 
Moloaÿa 2 6 3.0 0 
Continued … 
EXHIBIT A
Table 1.16 Hawaiian Home Lands by Households in Hawai‘i: 2010 
Hawaiian Home Land 
Total 
Households 
Persons In 
Households 
Average 
Household Size 
Persons in 
Group Quarters 
Nänäkuli 1,021 5,350 5.2 20 
Panaÿewa (Agricultural) 172 664 3.9 0 
Panaÿewa (Residential) 289 1,091 3.8 0 
Papakölea 256 1,215 4.8 0 
Paukükalo 169 810 4.8 8 
Pearl City 28 99 3.5 0 
Piÿihonua 17 46 2.7 0 
Ponohawaiÿi 4 21 5.3 0 
Princess Kahanu Estates 270 1,128 4.2 0 
Puÿukapu 259 898 3.5 0 
ÿUalapuÿe 1 2 2.0 0 
Waiähole 8 27 3.4 0 
Waiÿanae 443 2,201 5.0 0 
Waiÿanae Kai 148 609 4.1 0 
Waiehu 350 1,330 3.8 0 
Wailua 0 0 0.0 17 
Waimäÿnalo 658 3,002 4.6 46 
Waimanu 1 2 2.0 0 
Waiÿöhinu 3 6 2.0 0 
Waiohuli (Residential) 237 904 3.8 0 
Total 7,294 30,392 4.2 466 
All Household type percentages are of Total Households. 
Report generated by MO Census Data Center on 23MAY11 from setup in hhgqs_report.sas in dpro2010/Tools using 
acs2010.hipros data. 
Source: U.S. Census Bureau , 2010 Census. 2010 Census Re districting Data (Public Law 94-171) Summary 
File, Tables P1 and P2.
Panaewa 
(Residential) 
Waiakea 
Piihonua 
Keahuolu 
Homuula-Upper Piihonua 
Keaukaha 
Kamaoa-Puueo 
Panaewa (Agricultural) 
Kaumana 
Kawaihae 
Waiohinu 
Lalamilo Puukapu 
Kamoku-Kapulena 
Nienie 
Pauahi 
Honokaia 
Wailau 
Makuu 
Honomu 
Ponohawaii 
Kolaoa 
Kealakehe 
Kaohe-Olaa 
Keoniki 
Waimanu 
Upolu 
0 5 10 20 
Miles 
2010 HAWAIIAN HOME LANDS 
This map was produced by the Office of 
Planning (OP) for planning purposes. 
It should not be used for boundary inter-pretations 
or other spatial analysis beyond 
the limitations of the data. Information 
regarding compilation dates and accuracy of 
the data presented can be obtained from OP. 
Map No.: 20110628-02-DK 
Map Date: 06/28/11 
Sources: 
U.S. Census Bureau, 2010. 
Hawaii County
Kalawahine 
Waimanalo 
Kalaeloa 
0 2.5 5 10 
Nanakuli 
Maluohai 
Makaha 
Valley 
Waianae 
Lualualei 
Haiku 
Miles 
Waianae 
Kai Kakaina-Kumuhau 
Papakolea 
Honolulu 
Makai 
Waiahole 
Kewalo 
Princess 
Kahanu 
Estates 
Pearl 
City 
Kapolei 
Kaupea 
East 
Kapolei 
Kanehili 
Maili 
2010 HAWAIIAN HOME LANDS 
This map was produced by the Office of 
Planning (OP) for planning purposes. 
It should not be used for boundary inter-pretations 
or other spatial analysis beyond 
the limitations of the data. Information 
regarding compilation dates and accuracy of 
the data presented can be obtained from OP. 
Map No.: 20110628-04-DK 
Map Date: 06/28/11 
Sources: 
U.S. Census Bureau, 2010. 
Honolulu County
Niihau 
Kauai 
Waimea 
Hanapepe 
Anahola (Residential) 
Anahola (Agricultural) 
Moloaa 
Kapaa 
Wailua 
Kekaha 
0 2.5 5 10 
Miles 
2010 HAWAIIAN HOME LANDS 
This map was produced by the Office of 
Planning (OP) for planning purposes. 
It should not be used for boundary inter-pretations 
or other spatial analysis beyond 
the limitations of the data. Information 
regarding compilation dates and accuracy of 
the data presented can be obtained from OP. 
Map No.: 20110628-03-DK 
Map Date: 06/28/11 
Sources: 
U.S. Census Bureau, 2010. 
Kauai County
Kahoolawe 
2010 HAWAIIAN HOME LANDS 
Maui 
Molokai 
Lanai 
Kalaupapa 
Waiohuli 
(Residential) 
Keanae-Wailua 
Honokowai 
Hoolehua-Palaaau 
Leialii 
Kapaakea 
Pulehunui 
Kalamaula 
Paukukalo 
Kamiloloa-Makakupaia 
Keokea 
(Agricultural) 
Kahikinui 
Waiku-Hana 
Lanai 
City 
South 
Maui 
Ualapue 
Waiehu 
0 5 10 20 
Miles 
This map was produced by the Office of 
Planning (OP) for planning purposes. 
It should not be used for boundary inter-pretations 
or other spatial analysis beyond 
the limitations of the data. Information 
regarding compilation dates and accuracy of 
the data presented can be obtained from OP. 
Map No.: 20110628-05-DK 
Map Date: 06/28/11 
Sources: 
U.S. Census Bureau, 2010. 
Maui County
Blue Jay Wireless, LLC 
Wireless Lifeline Service Application and Certification HI-T 
A complete and signed Lifeline Service Application and Certification (“Certification”) is required to enroll you in Blue Jay Wireless, LLC’s (“the Company’s”) Lifeline service program 
in your state. This Certification is for the purpose of verifying your eligibility for Lifeline service. Service requests will not be processed until this Form has been received and 
verified by our Company. 
One Lifeline service per household disclosures: Lifeline is a government assistance program and willfully making false statements to obtain a Lifeline benefit can result in 
fines, imprisonment, de-enrollment or being barred from the program. Lifeline benefits are limited to a single line of service per household. A household is defined, for purposes 
of the Lifeline program, as any individual or group of individuals who live together at the same address and share income and expenses. A household may not receive multiple 
Lifeline discounts. You may apply your Lifeline discount to either one landline or one wireless number, but you cannot have the discount on both and you cannot receive Lifeline 
benefits from multiple providers. Note that not all Lifeline services are currently marketed under the name Lifeline. Lifeline is a non-transferable benefit and you may not 
transfer your benefit to any other person, including another eligible low-income consumer. Violation of the one-per-household limitation constitutes a violation of the Federal 
Communications Commission’s rules and will result in your de-enrollment from the program, and potentially prosecution by the United States Government. 
q I hereby certify under penalty of perjury that I have read and understood the disclosures listed above and that, to the best of my knowledge, my 
household is not already receiving a Lifeline service benefit. 
CUSTOMER APPLICATION INFORMATION: 
First Name Middle Name Last Name 
Date of Birth Last 4 of Social Security Number or Tribal ID Home Phone (if available) 
M M - D D - Y Y Y Y X X X - X X - - - 
Email (if available) 
If qualifying for Lifeline by income, number of individuals in household: Would you like to opt into electronic billing? q Yes q No 
RESIDENTIAL ADDRESS (P.O. BOX IS NOT SUFFICIENT): 
Street APT # 
City State Zip Code 
Address is (choose one): q Permanent q Temporary Service is (choose one): q New q Conversion 
BILLING ADDRESS (IF DIFFERENT FROM RESIDENTIAL ADDRESS) (P.O. BOX IS SUFFICIENT): 
Street APT # 
City State Zip Code 
CUSTOMER ELIGIBILITY CERTIFICATION: I hereby certify that I participate in at least one of the following programs (check one): 
q Supplemental Nutrition Assistance Program (SNAP)) q Section 8 Federal Public Housing Assistance (FPHA) q Low Income Home Energy Assistance Program (LIHEAP) 
q Medicaid (not Medicare) q Supplemental Security Income (SSI) 
q Temporary Assistance for Needy Families (TANF) q National School Lunch Program’s free lunch program 
OR, I hereby certify that I qualify for Lifeline pursuant to income eligibility: 
q Income at or below 135% of Federal Poverty Guidelines 
TRIBAL ELIGIBILITY: 
q I hereby certify that I reside on the Hawaiian Home Lands. 
If the beneficiary of the above program is different from the applicant, please state the name of the person receiving the benefit: 
q I hereby certify that the recipient of the above program lives in my household and does not receive Lifeline benefits from any other carrier. 
Beneficiary Name Date of Birth 
- - 
Multiple households sharing an address: 
q I hereby certify that I reside at an address occupied by multiple households, including adults who do not contribute income to my household and/or share in 
my household’s expenses, and I will complete a separate additional form. 
Return completed and signed form by email to: enroll@BlueJayWireless.com; by fax to 888.979.8316; or by mail to 5010 Addison Circle Addison, TX 75001 
Customer Service: 855.425.8529 
Last four of Social 
or Tribal ID 
EXHIBIT B 080814
Activation and usage requirement disclosures: This service is a prepaid service and you must personally activate it by calling 855-425-8529. To keep your account 
active, you must use your Lifeline service at least once during any 60 day period by completing an outbound call, purchasing additional minutes from Company, an-swering 
an in-bound call from someone other than Company, or by responding to a direct contact from Company confirming that you want to continue receiving Life-line 
service from Company. If your service goes unused for 60 days, you will no longer be eligible for Lifeline benefits and your service will be suspended (allowing 
only 611 and 911 calls and calls to the Company’s customer care center) subject to a 30 day cure period during which you may use the service (as described above) or 
contact the Company to confirm that you want to continue receiving Lifeline service from Company. 
q I hereby certify that I have read and understood the disclosures listed above regarding activation and usage requirements. 
Authorizations: 
q I hereby authorize the Company to access any records required to verify my statements on this form and to confirm my eligibility for the Lifeline program. I also 
authorize the Company to release any records required for the administration of the Lifeline program (name, telephone number, address, date of birth, last 4 digits 
of SSN or Tribal ID, amount of support being sought, means of qualification for support, and dates of service initiation and termination), including to the Universal 
Service Administrative Company, to be used in a Lifeline database and to ensure the proper administration of the Lifeline Program. Failure to consent will result 
in denial of service. 
Additional certifications: I hereby certify, under penalty of perjury, that (check each box): 
q I meet the income-based or program-based eligibility criteria for receiving Lifeline service and have provided documentation of eligibility if required 
q I will notify the Company within 30 days if for any reason I no longer satisfy the criteria for receiving Lifeline including, as relevant, if I no longer meet the 
income-based or program-based eligibility criteria, I begin receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline 
benefit. I understand that I may be subject to penalties if I fail to follow this requirement 
q I am not listed as a dependent on another person’s tax return (unless over the age of 60) 
q The address listed herein is my primary residence, not a second home or business 
q If I move to a new address, I will provide that new address to the Company within 30 days 
q If I provided a temporary residential address to the Company, I will verify my temporary residential address every 90 days 
q I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law 
q I acknowledge that I may be required to re-certify my continued eligibility for Lifeline at any time, and my failure to re-certify as to my continued eligibility within 
30 days will result in de-enrollment and the termination of my Lifeline benefits 
q The information contained in this certification form is true and correct to the best of my knowledge 
q If Blue Jay Wireless finds that I am already receiving a Lifeline discount benefit from another provider, I agree that I want to transfer my Lifeline discount benefit 
from that Lifeline provider to Blue Jay Wireless. I understand that once the transfer is complete, I will lose my Lifeline Program benefit with any other Lifeline 
provider from which I am currently receiving a Lifeline discount. Blue Jay Wireless has explained to me and I understand that I may not have multiple Lifeline 
Program benefits with the same or different providers. 
Applicant’s Signature: ____________________________________________________________________________________________________________ Date: _____________________________ 
For Agent Use Only (check the appropriate boxes for the proof of eligibility viewed and provide information requested; do not copy or retain documentation): 
Documents Acceptable Proof for Income-Eligibility (check 1): 
q The prior year’s state, federal or Tribal tax return, 
q Current income statement from an employer or paycheck stub, 
q A Social Security statement of benefits, 
q A Veterans Administration statement of benefits, 
q A retirement/pension statement of benefits, 
q An Unemployment/Workmen’s Compensation statement of benefits, 
q Federal or Tribal notice letter of participation in General Assistance, or 
q A divorce decree, child support award, or other official document contain-ing 
income information. 
If the documentation of income does not cover a full year, then applicant 
must present the same type of documentation covering 3 consecutive months 
within the previous 12 months. 
Applicant Account Number Rep/Agent Signature 
Place Phone Label Here 
Documents Acceptable Proof for Program-Eligibility 
(choose 1 from each list A and B below): 
List A - Choose 1 
q Supplemental Nutrition Assistance Program (SNAP) 
q Section 8 Federal Public Housing Assistance (FPHA) 
q Medicaid (not Medicare) 
q Supplemental Security Income (SSI) 
q Temporary Assistance for Needy Families (TANF) 
q Low Income Home Energy Assistance Program (LIHEAP) 
q National School Lunch Program’s free lunch program 
List B - Choose 1: 
q Program participation card/document 
q Prior year’s statement of benefits 
q Notice letter of participation 
q Other official document evidencing particiption 
____________________________________________________________________ 
Last 4 digits of Document from List B ________ ________ ________ 
Date of Proof Document: ________/_________/_________ 
Expiration Date of Proof Document: ________/_________/_________ 
Agent’s Name _______________________________________________________ Agent # ____________ Direct Phone Number ___________ - _____________ - _______________ 
Return completed and signed form by email to: enroll@BlueJayWireless.com; by fax to 888.979.8316; or by mail to 5010 Addison Circle Addison, TX 75001 
Customer Service: 855.425.8529 080814
EXHIBIT C
EXHIBIT D
Letter from Carl Caliboso about Blue Jay Wireless
Letter from Carl Caliboso about Blue Jay Wireless

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Letter from Carl Caliboso about Blue Jay Wireless

  • 1.
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  • 4.
  • 5. Table 1.16 Hawaiian Home Lands by Households in Hawai‘i: 2010 Hawaiian Home Land Total Households Persons In Households Average Household Size Persons in Group Quarters Anahola (Agricultural) 81 257 3.2 0 Anahola (Residential) 426 1,557 3.7 9 Hanapëpë 7 25 3.6 0 Homuÿula-Upper Piÿihonua 2 3 1.5 0 Honolulu Makai 0 0 0.0 13 Honomü 3 6 2.0 0 Hoÿolehua- Päläÿau 352 1,273 3.6 19 Kahikinui 1 3 3.0 0 Kalaÿeloa 0 0 0.0 10 Kalamaÿula 93 300 3.2 0 Kalaupapa 69 87 1.3 3 Kaläwahine 94 319 3.4 0 Kamäÿoa-Puÿuÿeo 7 14 2.0 0 Kamiloloa- Makakupaÿia 24 85 3.5 0 Kamoku- Kapulena 15 46 3.1 0 Kapaÿakea 42 141 3.4 0 Kaümana 35 111 3.2 0 Kaupeÿa 326 1,387 4.3 0 Kawaihae 131 405 3.1 2 Kealakehe 219 759 3.5 0 Keÿanae-Wailua 7 17 2.4 0 Keaukaha 407 1,582 3.9 2 Kekaha 114 483 4.2 0 Këökea (Agricultural) 9 24 2.7 0 Kewalo 51 261 5.1 0 Lälämilo 22 64 2.9 0 Länaÿi City 23 85 3.7 0 Leialiÿi 91 328 3.6 0 Lualualei 13 58 4.5 0 Mäÿili 1 6 6.0 317 Mäkaha Valley 1 4 4.0 0 Makuÿu 41 113 2.8 0 Maluöhai 251 1,178 4.7 0 Moloaÿa 2 6 3.0 0 Continued … EXHIBIT A
  • 6. Table 1.16 Hawaiian Home Lands by Households in Hawai‘i: 2010 Hawaiian Home Land Total Households Persons In Households Average Household Size Persons in Group Quarters Nänäkuli 1,021 5,350 5.2 20 Panaÿewa (Agricultural) 172 664 3.9 0 Panaÿewa (Residential) 289 1,091 3.8 0 Papakölea 256 1,215 4.8 0 Paukükalo 169 810 4.8 8 Pearl City 28 99 3.5 0 Piÿihonua 17 46 2.7 0 Ponohawaiÿi 4 21 5.3 0 Princess Kahanu Estates 270 1,128 4.2 0 Puÿukapu 259 898 3.5 0 ÿUalapuÿe 1 2 2.0 0 Waiähole 8 27 3.4 0 Waiÿanae 443 2,201 5.0 0 Waiÿanae Kai 148 609 4.1 0 Waiehu 350 1,330 3.8 0 Wailua 0 0 0.0 17 Waimäÿnalo 658 3,002 4.6 46 Waimanu 1 2 2.0 0 Waiÿöhinu 3 6 2.0 0 Waiohuli (Residential) 237 904 3.8 0 Total 7,294 30,392 4.2 466 All Household type percentages are of Total Households. Report generated by MO Census Data Center on 23MAY11 from setup in hhgqs_report.sas in dpro2010/Tools using acs2010.hipros data. Source: U.S. Census Bureau , 2010 Census. 2010 Census Re districting Data (Public Law 94-171) Summary File, Tables P1 and P2.
  • 7. Panaewa (Residential) Waiakea Piihonua Keahuolu Homuula-Upper Piihonua Keaukaha Kamaoa-Puueo Panaewa (Agricultural) Kaumana Kawaihae Waiohinu Lalamilo Puukapu Kamoku-Kapulena Nienie Pauahi Honokaia Wailau Makuu Honomu Ponohawaii Kolaoa Kealakehe Kaohe-Olaa Keoniki Waimanu Upolu 0 5 10 20 Miles 2010 HAWAIIAN HOME LANDS This map was produced by the Office of Planning (OP) for planning purposes. It should not be used for boundary inter-pretations or other spatial analysis beyond the limitations of the data. Information regarding compilation dates and accuracy of the data presented can be obtained from OP. Map No.: 20110628-02-DK Map Date: 06/28/11 Sources: U.S. Census Bureau, 2010. Hawaii County
  • 8. Kalawahine Waimanalo Kalaeloa 0 2.5 5 10 Nanakuli Maluohai Makaha Valley Waianae Lualualei Haiku Miles Waianae Kai Kakaina-Kumuhau Papakolea Honolulu Makai Waiahole Kewalo Princess Kahanu Estates Pearl City Kapolei Kaupea East Kapolei Kanehili Maili 2010 HAWAIIAN HOME LANDS This map was produced by the Office of Planning (OP) for planning purposes. It should not be used for boundary inter-pretations or other spatial analysis beyond the limitations of the data. Information regarding compilation dates and accuracy of the data presented can be obtained from OP. Map No.: 20110628-04-DK Map Date: 06/28/11 Sources: U.S. Census Bureau, 2010. Honolulu County
  • 9. Niihau Kauai Waimea Hanapepe Anahola (Residential) Anahola (Agricultural) Moloaa Kapaa Wailua Kekaha 0 2.5 5 10 Miles 2010 HAWAIIAN HOME LANDS This map was produced by the Office of Planning (OP) for planning purposes. It should not be used for boundary inter-pretations or other spatial analysis beyond the limitations of the data. Information regarding compilation dates and accuracy of the data presented can be obtained from OP. Map No.: 20110628-03-DK Map Date: 06/28/11 Sources: U.S. Census Bureau, 2010. Kauai County
  • 10. Kahoolawe 2010 HAWAIIAN HOME LANDS Maui Molokai Lanai Kalaupapa Waiohuli (Residential) Keanae-Wailua Honokowai Hoolehua-Palaaau Leialii Kapaakea Pulehunui Kalamaula Paukukalo Kamiloloa-Makakupaia Keokea (Agricultural) Kahikinui Waiku-Hana Lanai City South Maui Ualapue Waiehu 0 5 10 20 Miles This map was produced by the Office of Planning (OP) for planning purposes. It should not be used for boundary inter-pretations or other spatial analysis beyond the limitations of the data. Information regarding compilation dates and accuracy of the data presented can be obtained from OP. Map No.: 20110628-05-DK Map Date: 06/28/11 Sources: U.S. Census Bureau, 2010. Maui County
  • 11. Blue Jay Wireless, LLC Wireless Lifeline Service Application and Certification HI-T A complete and signed Lifeline Service Application and Certification (“Certification”) is required to enroll you in Blue Jay Wireless, LLC’s (“the Company’s”) Lifeline service program in your state. This Certification is for the purpose of verifying your eligibility for Lifeline service. Service requests will not be processed until this Form has been received and verified by our Company. One Lifeline service per household disclosures: Lifeline is a government assistance program and willfully making false statements to obtain a Lifeline benefit can result in fines, imprisonment, de-enrollment or being barred from the program. Lifeline benefits are limited to a single line of service per household. A household is defined, for purposes of the Lifeline program, as any individual or group of individuals who live together at the same address and share income and expenses. A household may not receive multiple Lifeline discounts. You may apply your Lifeline discount to either one landline or one wireless number, but you cannot have the discount on both and you cannot receive Lifeline benefits from multiple providers. Note that not all Lifeline services are currently marketed under the name Lifeline. Lifeline is a non-transferable benefit and you may not transfer your benefit to any other person, including another eligible low-income consumer. Violation of the one-per-household limitation constitutes a violation of the Federal Communications Commission’s rules and will result in your de-enrollment from the program, and potentially prosecution by the United States Government. q I hereby certify under penalty of perjury that I have read and understood the disclosures listed above and that, to the best of my knowledge, my household is not already receiving a Lifeline service benefit. CUSTOMER APPLICATION INFORMATION: First Name Middle Name Last Name Date of Birth Last 4 of Social Security Number or Tribal ID Home Phone (if available) M M - D D - Y Y Y Y X X X - X X - - - Email (if available) If qualifying for Lifeline by income, number of individuals in household: Would you like to opt into electronic billing? q Yes q No RESIDENTIAL ADDRESS (P.O. BOX IS NOT SUFFICIENT): Street APT # City State Zip Code Address is (choose one): q Permanent q Temporary Service is (choose one): q New q Conversion BILLING ADDRESS (IF DIFFERENT FROM RESIDENTIAL ADDRESS) (P.O. BOX IS SUFFICIENT): Street APT # City State Zip Code CUSTOMER ELIGIBILITY CERTIFICATION: I hereby certify that I participate in at least one of the following programs (check one): q Supplemental Nutrition Assistance Program (SNAP)) q Section 8 Federal Public Housing Assistance (FPHA) q Low Income Home Energy Assistance Program (LIHEAP) q Medicaid (not Medicare) q Supplemental Security Income (SSI) q Temporary Assistance for Needy Families (TANF) q National School Lunch Program’s free lunch program OR, I hereby certify that I qualify for Lifeline pursuant to income eligibility: q Income at or below 135% of Federal Poverty Guidelines TRIBAL ELIGIBILITY: q I hereby certify that I reside on the Hawaiian Home Lands. If the beneficiary of the above program is different from the applicant, please state the name of the person receiving the benefit: q I hereby certify that the recipient of the above program lives in my household and does not receive Lifeline benefits from any other carrier. Beneficiary Name Date of Birth - - Multiple households sharing an address: q I hereby certify that I reside at an address occupied by multiple households, including adults who do not contribute income to my household and/or share in my household’s expenses, and I will complete a separate additional form. Return completed and signed form by email to: enroll@BlueJayWireless.com; by fax to 888.979.8316; or by mail to 5010 Addison Circle Addison, TX 75001 Customer Service: 855.425.8529 Last four of Social or Tribal ID EXHIBIT B 080814
  • 12. Activation and usage requirement disclosures: This service is a prepaid service and you must personally activate it by calling 855-425-8529. To keep your account active, you must use your Lifeline service at least once during any 60 day period by completing an outbound call, purchasing additional minutes from Company, an-swering an in-bound call from someone other than Company, or by responding to a direct contact from Company confirming that you want to continue receiving Life-line service from Company. If your service goes unused for 60 days, you will no longer be eligible for Lifeline benefits and your service will be suspended (allowing only 611 and 911 calls and calls to the Company’s customer care center) subject to a 30 day cure period during which you may use the service (as described above) or contact the Company to confirm that you want to continue receiving Lifeline service from Company. q I hereby certify that I have read and understood the disclosures listed above regarding activation and usage requirements. Authorizations: q I hereby authorize the Company to access any records required to verify my statements on this form and to confirm my eligibility for the Lifeline program. I also authorize the Company to release any records required for the administration of the Lifeline program (name, telephone number, address, date of birth, last 4 digits of SSN or Tribal ID, amount of support being sought, means of qualification for support, and dates of service initiation and termination), including to the Universal Service Administrative Company, to be used in a Lifeline database and to ensure the proper administration of the Lifeline Program. Failure to consent will result in denial of service. Additional certifications: I hereby certify, under penalty of perjury, that (check each box): q I meet the income-based or program-based eligibility criteria for receiving Lifeline service and have provided documentation of eligibility if required q I will notify the Company within 30 days if for any reason I no longer satisfy the criteria for receiving Lifeline including, as relevant, if I no longer meet the income-based or program-based eligibility criteria, I begin receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline benefit. I understand that I may be subject to penalties if I fail to follow this requirement q I am not listed as a dependent on another person’s tax return (unless over the age of 60) q The address listed herein is my primary residence, not a second home or business q If I move to a new address, I will provide that new address to the Company within 30 days q If I provided a temporary residential address to the Company, I will verify my temporary residential address every 90 days q I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law q I acknowledge that I may be required to re-certify my continued eligibility for Lifeline at any time, and my failure to re-certify as to my continued eligibility within 30 days will result in de-enrollment and the termination of my Lifeline benefits q The information contained in this certification form is true and correct to the best of my knowledge q If Blue Jay Wireless finds that I am already receiving a Lifeline discount benefit from another provider, I agree that I want to transfer my Lifeline discount benefit from that Lifeline provider to Blue Jay Wireless. I understand that once the transfer is complete, I will lose my Lifeline Program benefit with any other Lifeline provider from which I am currently receiving a Lifeline discount. Blue Jay Wireless has explained to me and I understand that I may not have multiple Lifeline Program benefits with the same or different providers. Applicant’s Signature: ____________________________________________________________________________________________________________ Date: _____________________________ For Agent Use Only (check the appropriate boxes for the proof of eligibility viewed and provide information requested; do not copy or retain documentation): Documents Acceptable Proof for Income-Eligibility (check 1): q The prior year’s state, federal or Tribal tax return, q Current income statement from an employer or paycheck stub, q A Social Security statement of benefits, q A Veterans Administration statement of benefits, q A retirement/pension statement of benefits, q An Unemployment/Workmen’s Compensation statement of benefits, q Federal or Tribal notice letter of participation in General Assistance, or q A divorce decree, child support award, or other official document contain-ing income information. If the documentation of income does not cover a full year, then applicant must present the same type of documentation covering 3 consecutive months within the previous 12 months. Applicant Account Number Rep/Agent Signature Place Phone Label Here Documents Acceptable Proof for Program-Eligibility (choose 1 from each list A and B below): List A - Choose 1 q Supplemental Nutrition Assistance Program (SNAP) q Section 8 Federal Public Housing Assistance (FPHA) q Medicaid (not Medicare) q Supplemental Security Income (SSI) q Temporary Assistance for Needy Families (TANF) q Low Income Home Energy Assistance Program (LIHEAP) q National School Lunch Program’s free lunch program List B - Choose 1: q Program participation card/document q Prior year’s statement of benefits q Notice letter of participation q Other official document evidencing particiption ____________________________________________________________________ Last 4 digits of Document from List B ________ ________ ________ Date of Proof Document: ________/_________/_________ Expiration Date of Proof Document: ________/_________/_________ Agent’s Name _______________________________________________________ Agent # ____________ Direct Phone Number ___________ - _____________ - _______________ Return completed and signed form by email to: enroll@BlueJayWireless.com; by fax to 888.979.8316; or by mail to 5010 Addison Circle Addison, TX 75001 Customer Service: 855.425.8529 080814
  • 14.