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I acknowledge the obligation to re-certify my continued eligibility for Lifeline or Disabled benefits at any time and failure to re-certify my continued eligibility will result in de-enrollment and the termination of Lifeline or Disabled benefits. Company Use Only I hereby attest the applicant presented acceptable proof of eligibility Print name of company official Signature. Citizens Telephone Company of Higginsville Missouri Missouri Application for the Lifeline or Disabled Programs...

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The insert missouri-designated etc name is a specific name designated for a particular purpose in the state of Missouri.

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