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Company Use Only I hereby attest the applicant presented acceptable proof of eligibility Print name of company official Signature. 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. ORCHARD FARM TELEPHONE COMPANY Missouri Application for the Lifeline or Disabled Programs Consumers meeting certain...
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