DOCUMENTATION COVER SHEET

Please complete and return this COVER SHEET when submitting documentation to complete the
representative registration process. Place the completed coversheet on top of your documentation; do not
staple or paper clip). Mail the completed forms to:

Universal Service Administrative Company

Lifeline Support Center
P.0. Box 7081
London, KY
40742

DO NOT MAIL ORIGINAL DOCUMENTATION

Please only send photocopies or pictures of documentation.

**DO NOT MODIFY THE FORMAT OF THIS COVERSHEET**

PLEASE COMPLETE BELOW IN BLACK INK AND ALL CAPITAL LETTERS OR TYPE

Representative ID

1 H 2 8 7 7 K A Z

First Name

J O H N

Last Name
D I M A T E

Email Address

Please use the same email address you used when creating your account.

D I M A T E F E L I P E 6 @ G M A I L . C O M