letter from carl caliboso about blue jay wireless

Table 1.16 Hawaiian Home Lands by Households in Hawai‘i: 2010

Hawaiian Home Land Total

Households Persons In

Households Average

Household Size Persons in

Group Quarters

Anahola (Agricultural) 81 257 3.2 0

Anahola (Residential) 426 1,557 3.7 9

Hanapëpë 7 25 3.6 0

Homuÿula-Upper Piÿihonua 2 3 1.5 0

Honolulu Makai 0 0 0.0 13

Honomü 3 6 2.0 0

Hoÿolehua- Päläÿau 352 1,273 3.6 19

Kahikinui 1 3 3.0 0

Kalaÿeloa 0 0 0.0 10

Kalamaÿula 93 300 3.2 0

Kalaupapa 69 87 1.3 3

Kaläwahine 94 319 3.4 0

Kamäÿoa-Puÿuÿeo 7 14 2.0 0

Kamiloloa- Makakupaÿia 24 85 3.5 0

Kamoku- Kapulena 15 46 3.1 0

Kapaÿakea 42 141 3.4 0

Kaümana 35 111 3.2 0

Kaupeÿa 326 1,387 4.3 0

Kawaihae 131 405 3.1 2

Kealakehe 219 759 3.5 0

Keÿanae-Wailua 7 17 2.4 0

Keaukaha 407 1,582 3.9 2

Kekaha 114 483 4.2 0

Këökea (Agricultural) 9 24 2.7 0

Kewalo 51 261 5.1 0

Lälämilo 22 64 2.9 0

Länaÿi City 23 85 3.7 0

Leialiÿi 91 328 3.6 0

Lualualei 13 58 4.5 0

Mäÿili 1 6 6.0 317

Mäkaha Valley 1 4 4.0 0

Makuÿu 41 113 2.8 0

Maluöhai 251 1,178 4.7 0

Moloaÿa 2 6 3.0 0

Continued …

EXHIBIT A

Table 1.16 Hawaiian Home Lands by Households in Hawai‘i: 2010

Hawaiian Home Land Total

Households Persons In

Households Average

Household Size Persons in

Group Quarters

Nänäkuli 1,021 5,350 5.2 20

Panaÿewa (Agricultural) 172 664 3.9 0

Panaÿewa (Residential) 289 1,091 3.8 0

Papakölea 256 1,215 4.8 0

Paukükalo 169 810 4.8 8

Pearl City 28 99 3.5 0

Piÿihonua 17 46 2.7 0

Ponohawaiÿi 4 21 5.3 0

Princess Kahanu Estates 270 1,128 4.2 0

Puÿukapu 259 898 3.5 0

ÿUalapuÿe 1 2 2.0 0

Waiähole 8 27 3.4 0

Waiÿanae 443 2,201 5.0 0

Waiÿanae Kai 148 609 4.1 0

Waiehu 350 1,330 3.8 0

Wailua 0 0 0.0 17

Waimäÿnalo 658 3,002 4.6 46

Waimanu 1 2 2.0 0

Waiÿöhinu 3 6 2.0 0

Waiohuli (Residential) 237 904 3.8 0

Total 7,294 30,392 4.2 466

All Household type percentages are of Total Households.

Report generated by MO Census Data Center on 23MAY11 from setup in hhgqs_report.sas in dpro2010/Tools using

acs2010.hipros data.

Source: U.S. Census Bureau, 2010 Census. 2010 Census Redistricting Data (Public Law 94-171) Summary File, Tables P1 and P2.

Panaewa(Residential)

Waiakea

Piihonua

Keahuolu

Homuula-Upper Piihonua

Keaukaha

Kamaoa-Puueo

Panaewa (Agricultural)Kaumana

Kawaihae

Waiohinu

Lalamilo Puukapu

Kamoku-Kapulena

Nienie

Pauahi

Honokaia

Wailau

Makuu

Honomu

Ponohawaii

Kolaoa

Kealakehe

Kaohe-Olaa

Keoniki

WaimanuUpolu

0 10 205

Miles

2010 HAWAIIAN HOME LANDS

This map was produced by the Office ofPlanning (OP) for planning purposes.It should not be used for boundary inter-pretations or other spatial analysis beyond the limitations of the data. Informationregarding compilation dates and accuracy ofthe data presented can be obtained from OP.Map No.: 20110628-02-DKMap Date: 06/28/11Sources:U.S. Census Bureau, 2010.

Hawaii County

Kalawahine

Waimanalo

Kalaeloa

Maluohai

Nanakuli

MakahaValley

Waianae

Lualualei

Haiku

WaianaeKai Kakaina-Kumuhau

Papakolea

HonoluluMakai

Waiahole

Kewalo

PrincessKahanuEstates

PearlCity

Kaupea

Kapolei

EastKapolei

Kanehili

Maili

0 5 102.5

Miles



Honolulu County

Niihau

Kauai

Waimea

Hanapepe

Anahola (Residential)

Anahola (Agricultural)Moloaa

Kapaa

Wailua

Kekaha

0 5 102.5

Miles



Kauai County

Kahoolawe

Maui

Lanai

MolokaiKalaupapa

Waiohuli(Residential)

Keanae-Wailua

Honokowai

Hoolehua-Palaaau

Leialii

Kapaakea

Pulehunui

Kalamaula

Paukukalo

Kamiloloa-Makakupaia

Keokea(Agricultural)

Kahikinui

Waiku-Hana

LanaiCity

SouthMaui

Ualapue

Waiehu

0 10 205

Miles



Maui County

q I hereby certify under penalty of perjury that I have read and understood the disclosures listed above and that, to the best of my knowledge, my household is not already receiving a Lifeline service benefit.

CUSTOMER APPLICATION INFORMATION:First Name Middle Name Last Name

Date of Birth Last 4 of Social Security Number or Tribal ID Home Phone (if available)M M - D D - Y Y Y Y X X X - X X - - -Email (if available)

If qualifying for Lifeline by income, number of individuals in household: Would you like to opt into electronic billing? q Yes q No

RESIDENTIAL ADDRESS (P.O. BOX IS NOT SUFFICIENT):

Street APT #

City State Zip Code

Address is (choose one): q Permanent q Temporary Service is (choose one): q New q Conversion

BILLING ADDRESS (IF DIFFERENT FROM RESIDENTIAL ADDRESS) (P.O. BOX IS SUFFICIENT):Street APT #

City State Zip Code

CUSTOMER ELIGIBILITY CERTIFICATION: I hereby certify that I participate in at least one of the following programs (check one): q Supplemental Nutrition Assistance Program (SNAP)) q Section 8 Federal Public Housing Assistance (FPHA) q Low Income Home Energy Assistance Program (LIHEAP) q Medicaid (not Medicare) q Supplemental Security Income (SSI) q Temporary Assistance for Needy Families (TANF) q National School Lunch Program’s free lunch program

OR, I hereby certify that I qualify for Lifeline pursuant to income eligibility: q Income at or below 135% of Federal Poverty Guidelines

TRIBAL ELIGIBILITY: q I hereby certify that I reside on the Hawaiian Home Lands.If the beneficiary of the above program is different from the applicant, please state the name of the person receiving the benefit: q I hereby certify that the recipient of the above program lives in my household and does not receive Lifeline benefits from any other carrier. Beneficiary Name Date of Birth

- -

Multiple households sharing an address: q I hereby certify that I reside at an address occupied by multiple households, including adults who do not contribute income to my household and/or share in

my household’s expenses, and I will complete a separate additional form.

Return completed and signed form by email to: [email protected]; by fax to 888.979.8316; or by mail to 5010 Addison Circle Addison, TX 75001 Customer Service: 855.425.8529

A complete and signed Lifeline Service Application and Certification (“Certification”) is required to enroll you in Blue Jay Wireless, LLC’s (“the Company’s”) Lifeline service program in your state. This Certification is for the purpose of verifying your eligibility for Lifeline service. Service requests will not be processed until this Form has been received and verified by our Company.

One Lifeline service per household disclosures: Lifeline is a government assistance program and willfully making false statements to obtain a Lifeline benefit can result in fines, imprisonment, de-enrollment or being barred from the program. Lifeline benefits are limited to a single line of service per household. 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. A household may not receive multiple Lifeline discounts. You may apply your Lifeline discount to either one landline or one wireless number, but you cannot have the discount on both and you cannot receive Lifeline benefits from multiple providers. Note that not all Lifeline services are currently marketed under the name Lifeline. Lifeline is a non-transferable benefit and you may not transfer your benefit to any other person, including another eligible low-income consumer. Violation of the one-per-household limitation constitutes a violation of the Federal Communications Commission’s rules and will result in your de-enrollment from the program, and potentially prosecution by the United States Government.

Blue Jay Wireless, LLC Wireless Lifeline Service Application and Certification HI-T

Last four of Social or Tribal ID

080814EXHIBIT B

Activation and usage requirement disclosures: This service is a prepaid service and you must personally activate it by calling 855-425-8529. To keep your account active, you must use your Lifeline service at least once during any 60 day period by completing an outbound call, purchasing additional minutes from Company, an-swering an in-bound call from someone other than Company, or by responding to a direct contact from Company confirming that you want to continue receiving Life-line service from Company. If your service goes unused for 60 days, you will no longer be eligible for Lifeline benefits and your service will be suspended (allowing only 611 and 911 calls and calls to the Company’s customer care center) subject to a 30 day cure period during which you may use the service (as described above) or contact the Company to confirm that you want to continue receiving Lifeline service from Company.

q I hereby certify that I have read and understood the disclosures listed above regarding activation and usage requirements.

Authorizations:q I hereby authorize the Company to access any records required to verify my statements on this form and to confirm my eligibility for the Lifeline program. I also

authorize the Company to release any records required for the administration of the Lifeline program (name, telephone number, address, date of birth, last 4 digits of SSN or Tribal ID, amount of support being sought, means of qualification for support, and dates of service initiation and termination), including to the Universal Service Administrative Company, to be used in a Lifeline database and to ensure the proper administration of the Lifeline Program. Failure to consent will result in denial of service.

Additional certifications: I hereby certify, under penalty of perjury, that (check each box):q I meet the income-based or program-based eligibility criteria for receiving Lifeline service and have provided documentation of eligibility if requiredq I will notify the Company 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 eligibility criteria, I begin receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline benefit. I understand that I may be subject to penalties if I fail to follow this requirement

q I am not listed as a dependent on another person’s tax return (unless over the age of 60)q The address listed herein is my primary residence, not a second home or businessq If I move to a new address, I will provide that new address to the Company within 30 daysq If I provided a temporary residential address to the Company, I will verify my temporary residential address every 90 daysq I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by lawq I acknowledge that I may be required to re-certify my continued eligibility for Lifeline at any time, and my failure to re-certify as to my continued eligibility within

30 days will result in de-enrollment and the termination of my Lifeline benefits q The information contained in this certification form is true and correct to the best of my knowledgeq If Blue Jay Wireless finds that I am already receiving a Lifeline discount benefit from another provider, I agree that I want to transfer my Lifeline discount benefit

from that Lifeline provider to Blue Jay Wireless. I understand that once the transfer is complete, I will lose my Lifeline Program benefit with any other Lifeline provider from which I am currently receiving a Lifeline discount. Blue Jay Wireless has explained to me and I understand that I may not have multiple Lifeline Program benefits with the same or different providers.

Applicant’s Signature: ____________________________________________________________________________________________________________ Date: _____________________________

Documents Acceptable Proof for Income-Eligibility (check 1):q The prior year’s state, federal or Tribal tax return, q Current income statement from an employer or paycheck stub, q A Social Security statement of benefits, q A Veterans Administration statement of benefits, q A retirement/pension statement of benefits, q An Unemployment/Workmen’s Compensation statement of benefits, q Federal or Tribal notice letter of participation in General Assistance, or q A divorce decree, child support award, or other official document contain-

ing income information.

If the documentation of income does not cover a full year, then applicant must present the same type of documentation covering 3 consecutive months within the previous 12 months.

Applicant Account Number Rep/Agent Signature

Place Phone Label Here

Documents Acceptable Proof for Program-Eligibility (choose 1 from each list A and B below):

List A - Choose 1q Supplemental Nutrition Assistance Program (SNAP)q Section 8 Federal Public Housing Assistance (FPHA)q Medicaid (not Medicare)q Supplemental Security Income (SSI)q Temporary Assistance for Needy Families (TANF)q Low Income Home Energy Assistance Program (LIHEAP) q National School Lunch Program’s free lunch program

List B - Choose 1:q Program participation card/documentq Prior year’s statement of benefitsq Notice letter of participationq Other official document evidencing particiption ____________________________________________________________________

Last 4 digits of Document from List B ________ ________ ________Date of Proof Document: ________/_________/_________ Expiration Date of Proof Document: ________/_________/_________

For Agent Use Only (check the appropriate boxes for the proof of eligibility viewed and provide information requested; do not copy or retain documentation):

Agent’s Name _______________________________________________________ Agent # ____________ Direct Phone Number ___________ - _____________ - _______________

Return completed and signed form by email to: [email protected]; by fax to 888.979.8316; or by mail to 5010 Addison Circle Addison, TX 75001Customer Service: 855.425.8529 080814

EXHIBIT C

EXHIBIT D

letter from carl caliboso about blue jay wireless

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