Line Extension Customer Assistance Program - Individual Referral Portal

on behalf of an Individual

Submit Application

Application Submission Steps:

All fields marked With * Are required for submissions. Click Please Note: Fields marked with + are required if address information is is not the same as applicant's

Please Note: Most questions can be answered with Yes Or No. Some questions may require you to enter in longer form answers.

When form is complete please submit it to DHCD by clicking the Submit Button.

If you have an questions please contact: DHCD LECAP Program.

Fields Marked With * Are Required For Application Submission
Referring Individual Information:

Applicant Information:

The information below should be completed with information from proposed LECAP Beneficiary:

Property Questions and Information:

Please answer the questions below with Yes or No

*Is this the Primary Residential Address of the individual listed above?

Yes | No

If the applicant receives mail at a different place than the physical applicant address listed above, please provide the information below.

Mailing Address:

Applicant Information Continued:

Please answer the questions below with Yes or No

*Is the applicant’s current monthly gross household income when multiplied by 12 (12 x the applicant’s monthly gross income) less than or equal to $170,340.00? DHCD will send a secure email requesting documentation of income after the application is completed.?

Yes | No

______________

*The Affordable Connectivity Program is an Federal Communications Commission (FCC) program that helps connect families and households struggling to afford internet service by offering up to a $30 per month discount for services. The applicant may qualify for the program if the applicant’s income is below 200% of the Federal Poverty Guidelines or if the applicant participates in certain assistance programs such as SNAP, Medicaid, Federal Public Housing Assistance, SSI, WIC, or Lifeline. If the applicant is eligible, would the applicant like to take part in the Affordable Connectivity Program?

Yes | No

Written Permission of Applicant:

DHCD will request documentation of written permission of the LECAP applicant permitting the Caretaker identified in this application to apply for LECAP benefits on the behalf of the individual identified in this application, as well as any documentation of income (Paystubs, tax returns, or documentation of benefits) for the individual identified in this application using a secured email.

Yes

Applicant Information Continued: Please answer the questions below by filling the boxes below each question

*How Many individuals consider their Primary Address at the property listed above?

*How many individuals who consider the property as their primary address are employed or have an income? This includes those receiving Social Security and disability payments. DHCD will send a secure email requesting documentation of income after the application is completed.

*Please identify the Internet Service Providers that the applicant wishes to recieve service from if provided benefits through LECAP.
(If you are unsure leave this field blank)

Certification Statement: Please answer the questions below with Yes or No

*I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in the application may render this Application void and will be cause for termination, whenever discovered.***

Yes | No