The Federal Lifeline and California LifeLine Programs (referred to below as “Lifeline”) provide discounts on talk, text and data services for qualifying low-income individuals. The Lifeline benefits and discount, which are provided through Excess Telecom’s affiliate IM Telecom, LLC , may be applied to plans offered by Excess Telecom. Some restrictions may apply. You may choose to get Lifeline services from other providers. You may also transfer your Lifeline services to another provider subject to certain regulatory restrictions.
By reviewing the disclosures and providing the consents below, you agree to receive Lifeline benefits from IM Telecom and apply your Lifeline discount benefits to an Excess Telecom branded plan. Lifeline services are available only in states where IM Telecom is authorized as a Lifeline provider. IM Telecom has contracted with Excess Telecom to provide support and enable you to apply your Lifeline benefits to Excess Telecom branded plans (“Excess Telecom powered by IM Telecom”). Your application of IM Telecom Lifeline program discounts to an Excess Telecom branded plan is subject to the Terms and Conditions available at
www.infinitimobile.com.
E-sign Certification - I consent to the use of this electronic form. I understand I have the right to enroll in the service using non-electronic methods. I further understand that I have the right to withdraw this consent at any time prior to the activation of my service. Excess Telecom has advised me and I understand that I may request a paper copy of my contractual terms and associated fees or withdraw this consent by calling 1-800-615-0898.
Service Activation and Usage Requirement
- I understand Excess Telecom’s Lifeline Advantage, Lifeline Advantage – California (pending CPUC approval) and Lifeline Advantage Tribal plans (pending CPUC approval in California) require an annual deposit of $12 at the time of enrollment that is placed in my eWallet account and may be used to pay the monthly $1 service fee for the Lifeline Advantage plans. I understand that I control any deposits placed in my eWallet account and may request that it be refunded to me at any time. Funds deposited into my eWallet may be used to pay the monthly service fee for any Excess Telecom plan in which I am a subscriber. I will receive a monthly SMS text about the monthly service fee indicating it will be paid from my eWallet account unless I request otherwise. I may review the Terms and Conditions at www.infinitimobile.com to learn more about the refunding of unused balances in my account.
- If my service with Excess Telecom powered by IM Telecom ends with deposited or other unused funds in my eWallet account, I understand that these funds belong to me and Excess Telecom will return them to me according to my preference. I must contact Excess Telecom to request how I would like to receive a refund. I may be asked to provide a valid mailing address for the mailing of a refund check. If I don’t request a refund within sixty (60) days of de-enrollment, Excess Telecom will convert the remaining deposited amount in my eWallet account to data at a rate of 0.20 GB per $1 and place this data allocation on my SIM card. Excess Telecom will send me an SMS or email notification about this action. I will then have sixty (60) days to use this data on my SIM card. Unused data on my SIM card will be deleted at the end of this 60-day period and my account closed. If I request a refund after using converted data during the initial 30-day period in which converted data has been placed on my SIM card, the amount of data utilized will be converted to a monetary amount ($1 for each 0.20 GB) and deducted from the refund payment. I may request a refund at any time prior to the closing of my account.
- I understand that qualified Lifeline subscribers at the time of enrollment may be eligible to receive a free phone, purchase a phone, or get a free SIM card to use with their own device. Receipt of a free phone or the purchase of a phone is not guaranteed and may only be offered to qualifying subscribers If I select the SIM card option, I must enroll in one of the Lifeline Advantage plans. If I want to receive a SIM card and enroll in a Lifeline Standard plan, I may need to call customer service at 1-800-615-0898 to enroll.
- I agree and acknowledge that my Lifeline service will be activated upon submitting the application form and completing the eligibility verification, enrollment and plan selection processes, as applicable. To keep my Lifeline Standard, Lifeline Standard - California or Lifeline Standard Tribal plan account active, I must use the service at least once during any 30-day period by completing an outbound call, sending a text message, using cellular data, purchasing additional service, answering an in-bound call from someone other than Excess Telecom, or by responding to a direct contact from Excess Telecom confirming that I want to continue receiving my Lifeline benefits. If my service goes unused for 30 days, I will no longer be eligible for Lifeline benefits and my service may be suspended (while allowing 911 calls) subject to a 15-day cure period during which I must use the service (as described above) to fully re-activate my service, keep my telephone number and remain enrolled in Lifeline. This usage requirement for subscribers enrolled in the Lifeline Advantage, Lifeline Advantage – California (pending CPUC approval) or Lifeline Advantage Tribal plans (pending CPUC approval in California) is met by the monthly service fee paid by these subscribers.
- I hereby certify that I have read and understood the disclosures listed above, including those regarding activation and usage requirements.
- I authorize Excess Telecom and its affiliate IM Telecom, and their contracted partners for the purpose of applying for, determining eligibility, enrolling in and seeking reimbursement of Lifeline benefits, to collect, use, share, and retain my personal information, including but not limited to information required for the purpose of establishing eligibility for and enrolling in the Lifeline program, and including, but not limited to, full name, full residential address, date of birth, last four digits of social security number, telephone number, eligibility criteria and status, the date on which the Lifeline service discount was initiated and if applicable, terminated, usage status and other compliance requirements, the amount of support being sought for the service, and information necessary to establish identity and verifiable address. This information may be shared with USAC to ensure proper administration of the Lifeline program. Failure to provide consent will result in me being denied Lifeline benefits and service.
Lifeline Disclosures, Consents and Certifications Federal Lifeline and California LifeLine are government assistance benefit programs. Federal Lifeline is operated by the Federal Communications Commission (FCC) and California LifeLine by the California Public Utilities Commission (CPUC). These Lifeline programs provide discounts on monthly broadband Internet access service, text and/or voice service. You are agreeing to receive Lifeline benefits from IM Telecom and apply your Lifeline discount benefits to an Excess Telecom branded plan. Your application of IM Telecom Lifeline program discounts to an Excess Telecom branded plan is subject to the Terms and Conditions available at
www.infinitimobile.com.
Willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the Lifeline program.
Only one Lifeline benefit is available per household. A household is not permitted to receive discounted Lifeline services from multiple providers. 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. Violation of the one-per-household limitation constitutes a violation of the FCC's rules and will result in you being de-enrolled from the Lifeline program. Lifeline discount benefits are not transferrable to other households or persons.
Eligibility for Lifeline is determined by the National Verifier and National Lifeline Accountability Database, administered by the Universal Service Administrative Company (USAC). In California and Texas, state administrators are involved in determining eligibility.
- I hereby certify that I have read and understood the disclosures listed above regarding Lifeline benefits and consent to enroll in Lifeline with IM Telecom and to apply my Lifeline discount benefit to an Excess Telecom branded plan powered by IM Telecom.
Lifeline Benefit Transfer Consent - I consent to and authorize the transfer of my current Lifeline benefit to IM Telecom, if I am found to already be receiving a Lifeline discount benefit from another Lifeline provider. A subscriber already enrolled in Lifeline with another provider must consent to the transfer of their Lifeline benefit to another provider. The effect of a Lifeline benefit transfer is that my Lifeline benefit will be provided by IM Telecom and applied to an Excess Telecom branded plan powered by IM Telecom and will no longer be applied to service retained from my former Lifeline service provider. I may be subject to my former Lifeline provider’s undiscounted rates due to the transfer if I elect to maintain service from that provider.
- I understand and accept that to address the prevalence of benefit transfers to another provider without subscriber consent, Excess Telecom will automatically transfer back my Lifeline service if this occurs within 120-days of enrollment with Excess Telecom powered by IM Telecom unless I confirm the service transfer. I acknowledge consenting to this automatic transfer back of Lifeline service with Excess Telecom powered by IM Telecom with this enrollment. Excess Telecom will notify me by text message and/or email to confirm a service transfer to another provider if it occurs within 120 days of this enrollment. If I do not confirm this Lifeline service transfer to another provider within forty-eight (48) hours of receiving an Excess Telecom text or email communication, my Lifeline service will be transferred back to my previous Excess Telecom plan powered by IM Telecom. I may also rescind consent to this 120-day automatic transfer-back enrollment policy by contacting Excess Telecom’s Customer Service at 1-800-615-0898. This does not apply to California Lifeline subscribers.
Lifeline Benefit Enrollment Pre-consent
- I acknowledge and understand that if IM Telecom has applied for approval to offer federal Lifeline benefits in my state of residence, my enrollment in Lifeline with IM Telecom is subject to such approval and I consent to such enrollment provided approval is received within ninety (90) calendar days of the date of this consent. If approval is not received within such a timeframe, I understand that I will need to reapply after that period.
Assessing Eligibility for Lifeline Benefits
- I acknowledge that Excess Telecom may use my application to assess my eligibility for benefits under this government program. I understand that Excess Telecom may request reports from CGM, LLC, located at 104 Sloan Street, Roswell, Georgia 30075, telephone number (888) 594-3860. These reports may include information from phone or internet providers regarding my service enrollment history, or the frequency with which I have received wireless devices, which may be used for determinations regarding my eligibility for a device, device discounts, a SIM card, and for waste, fraud and abuse mitigation purposes.
- For California residents: Under California Civil Code § 1786.22, I understand that I have the right to request from CGM, upon proper identification, the nature and substance of all information in files pertaining to me, including the sources of information, and recipients of any reports about me, which CGM has previously furnished within the preceding three-year period. I am aware that I may view the file maintained on me by CGM during normal business hours and obtain a copy of this file upon submitting proper identification. Upon making a written request, I am entitled to receive a summary of this file.
Lifeline Eligibility Criteria and Electronically Initialed Certifications: - Program eligibility: California LifeLine Program
- You must acknowledge each of the certifications below individually and under penalty of perjury:
- I meet the income-based or program-based eligibility criteria for Lifeline in FCC rule 47 C.F.R. § 54.409;
- I will notify IM Telecom 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 criteria for receiving Lifeline support, I am receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline benefit;
- If I am seeking to qualify for Lifeline as an eligible resident of Tribal lands, I live on Tribal lands, as defined in FCC rule 47 C.F.R. 54.400(e);
- If I move to a new address, I will provide that new address to IM Telecom within 30 days;
- My household will receive only one Lifeline service and, to the best of my knowledge, my household is not already receiving a Lifeline service;
- The information contained in this certification form is true and correct to the best of my knowledge; I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law; and
- I acknowledge that I may be required to re-certify my continued eligibility for Lifeline at any time, and my failure to re-certify my continued eligibility will result in de-enrollment and the termination of my Lifeline benefits pursuant to FCC rule 47 C.F.R. § 54.405(e)(4).
Consent to Receive Communications
- I authorize and give express consent to being contacted by Excess Telecom via email and telephone, including calls or messages using an automated telephone dialing system, manually, or with pre-recorded/artificial voice messages. Excess Telecom may contact me for service-related, informational, or marketing purposes via these methods. I also provide express consent to be contacted, regardless of whether my number is listed on the Do-Not-Call Registry or a state equivalent registry. Consent to such contacts is not a condition of service and may be revoked at any time. Consent for emails and calls is optional and can be revoked at any time by dialing 611 from my Excess Telecom provided wireless number or by calling 1-800-615-0898 and revoking consent. I understand that opting out will not affect Excess Telecom’s ability to contact me with free notices and messages regarding my wireless service and devices and my Lifeline benefits via the methods listed herein. For more information I may refer to the Terms and Conditions at
www.infinitimobile.com and Privacy Policy at
www.excesstelecom.com.
- I authorize and give express consent to being contacted by Excess Telecom via text messaging. Excess Telecom may contact me for service-related, informational, or marketing purposes. Message frequency may vary, and message and data rates may apply. Consent to such contact is not a condition of service and may be revoked at any time. Consent to receive texts is optional and may be revoked at any time by texting “STOP” to Excess Telecom, dialing 611 from your Excess Telecom provided wireless number or by calling 1-800-615-0898 and revoking consent. I understand that opting out will not affect Excess Telecom’s ability to contact me with free messages regarding my wireless service and devices and Lifeline benefits via the methods listed herein. For more information I may refer to the Terms and Conditions at
www.infinitmobile.com and Privacy Policy at
www.excesstelecom.com.
- I authorize and give express consent for Excess Telecom to use and share my Customer Proprietary Network Information (CPNI) for marketing purposes, including but not limited to sharing my CPNI with affiliates of Excess Telecom. I authorize and give express consent for affiliates of Excess Telecom to contact me about offerings of non-communications-related services, products, and promotions. You have a right, and Excess Telecom has a duty, under federal law, to protect the confidentiality of CPNI. CPNI is information made available to us solely by virtue of our relationship with you that relates to the type, quantity, destination, technical configuration, geolocation data, and amount of use of the telecommunications services you purchase from us, as well as information related to the billing for those services. CPNI does not include subscriber list information, such as name, postal address, or telephone number. You will continue to receive Excess Telecom communications services if you choose to not consent. CPNI is described in our Privacy Policy at
www.excesstelecom.com. You may withdraw your consent at any time by reaching us as described in our Privacy Policy.
Certification of Truth and Correctness Under Penalty of Perjury - By completing the form below, I hereby certify, under penalty of perjury, that the information included in this application and the certifications provided herein are true and correct to the best of my knowledge. I understand that willfully making false statements to obtain benefits may result in fines, imprisonment, de-enrollment, or being denied benefits.
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