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Application

Name *

First

Name

Middle

Name *

Last

Name

Suffix

Last 4 of SSN *

Drivers License/Govt. ID # *

Date of Birth *

MM/DD/YR

Email *

Phone *

Preferred Method of Contact *

Phone

Text

Address

NOTE: Your address must match the address EXACTLY how it is on your Government-Sponsored Benefits. P.O. Boxes and Business Addresses are not acceptable. If you live in a shelter, transitional home, hotel/motel, nursing home, or any rehab (drug, physical, or mental facility), or have a Post Office General Delivery address please use that as your address and specify the name of the facility on the line below and include the main contact number of that facility if there is one. The Lifeline Program & Lifeline Experts will attempt to obtain an address waiver, but we must have an alternate address to which we can ship your device once you are approved. If you are homeless, please state the address where you currently receive mail or last received mail. If you don't receive mail anywhere, write HOMELESS in the address field and provide us with an alternate address so we can ship your device to you once you are approved.

Address *

Address (Continued)

Alternate Address Continued

Alternate Address *

This household is on qualifying tribal land.

Yes

City *

State/Territory

Zip Code

Radio Buttons

Medicaid

SNAP (Food Stamps)

SSI (Supplemental Security Income)

Veterans Pension or Survivor Benefits

WIC (Women Infants Children)

Section 8

Pell Grant

School Breakfast/School Lunch Program

Federal Public Housing Assistance

Income Qualifications

For those individuals who are not on any of the approved Govt. Benefits Programs, you may apply for a FREE Smartphone under the Income Qualifications rule if you can show proof of the following;

Your (or your dependent’s) first and last name
Your annual income
To show documentation of income that does not cover a full year, such as current pay stubs, the documentation must cover three months in a row within the past twelve months

Document Examples:

Prior year’s state, federal, or Tribal tax return
Current income statement from your employer or a paycheck stub
A Social Security statement of benefits
Veterans Administration statement of benefits
Unemployment or Worker’s Compensation statement of benefits
Divorce decree, child support award, or a similar official document showing your income
A retirement/pension statement of benefits
Your (or your dependent’s) first and last name
Your annual income
To show documentation of income that does not cover a full year, such as current pay stubs, the documentation must cover three months in a row within the past twelve months

Here are the ways your household can qualify for the Affordable Connectivity Program:

Based on your household income
If you or your child or dependent participate in certain government assistance programs such as SNAP, Medicaid, WIC, or other programs
If you or anyone in your household already receives a Lifeline benefit
Note: You may qualify for the Lifeline Program through a participating provider’s existing low-income program. Visit our How to Apply page to learn more.

My Application is based on my income.

My annual household income is 200% or less than the Federal Poverty Guidelines (the amount listed in the Federal Poverty Guidelines table on this form). Must check if applying on Income Qualifications only.

If you have any questions concerning Income Qualifications in applying for The Affordable Connectivity or Life Lifeline Program, contact our Customer Service at (386) 601-4391 and we will answer all of your questions.

I am older than 18 years old.

I am the authorized person to make decisions for Internet services and to change the Internet Service Provider.

I give The Lifeline Program the exclusive authority to select on my behalf the Wireless Broadband Service Provider of my choosing and has my permission to retain exclusive authority to select the appropriate Service Provider, Wireless or Data Plan, Equipment, and will act as my personal representative and fiduciary in respects to all decisions concerning my enrollment or transfer in the Affordable Connectivity Program and Lifeline Program.

I'm going to go over the required information to participate in the Lifeline Program Answering affirmatively is required in order to enroll in the Lifeline Program in my state. This authorization is only for the purpose of verifying my participation in this program and will not be used for any purpose other than the Lifeline Program.

I am authorizing the company, The Lifeline Program to access any records required to verify my statements on this form and to confirm my eligibility for the Lifeline Program and share this information with the Provider of my wireless, broadband, fiber optic, or satellite Internet services. This will also be applicable to any Telecommunications hardware or equipment such as cell phones, hotspots, wireless routers or access points, desktop or laptop computers or any accessories that relate to any of the above just mentioned.

For my household, I affirm and understand that the Lifeline Program is a temporary federal government subsidy that reduces my broadband internet access service bill and at the conclusion of the program, my household will be subject to the provider's undiscounted general rates, terms, and conditions if my household continues to subscribe to the service.

I agree that if I move I will provide my new address to my service provider within 30 days.

I understand that I have to tell my service provider within 30 days if I do not qualify for Lifeline Program benefits anymore, including I, or the person in my household that qualifies, do not qualify through a government program or income anymore.

No one else is getting Affordable Connectivity Program benefits at my house right now.

I know that my household can only get one Lifeline Program benefit and, to the best of my knowledge, my household is not getting more than one Lifeline Program benefit. I understand that I can only receive one connected device (Cell Phones) through the Lifeline Program benefit, even if I switch providers.

I agree that all of the information I provide on this form may be collected, used, shared, and retained for the purposes of applying for and/or receiving the Lifeline Program benefit. I understand that if this information is not provided to the Program Administrator, I will not be able to get Lifeline Program benefits. If the laws of my state or Tribal government require it, I agree that the state or Tribal government may share information about my benefits for a qualifying program with the Lifeline Program Administrator. The information shared by the state or Tribal government will be used only to help find out if I can get an Lifeline Program benefit.

I agree that The Lifeline Program can contact me at any time to follow up on my subscription and future service offerings. I understand and agree to the terms and conditions of the Lifeline Program. If I am enrolled ot transferred by anyone other entity, The Lifeline Program has my permission to transfer my services to whichever carrier they deem appropriate at that time even if it's a different carrier than the one previous as my new Lifeline Service Provider. All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.

I hereby certify that I have read this thoroughly and agreed to these disclosures.

I understand that agreeing to these terms and submitting this form is the equivalent of a legal signature.

Choose Your Smart Phone

Choose Your Cell Phones

If you are human, leave this field blank.

Application

Name *

First

Name

Middle

Name *

Last

Name

Suffix

Last 4 of SSN *

Drivers License/Govt. ID # *

Date of Birth *

MM/DD/YR

Email *

Phone *

Preferred Method of Contact *

Phone

Text

Address

Address *

Address (Continued)

Alternate Address Continued

Alternate Address *

This household is on qualifying tribal land.

Yes

City *

State/Territory

Zip Code

Radio Buttons

Medicaid

SNAP (Food Stamps)

SSI (Supplemental Security Income)

Veterans Pension or Survivor Benefits

WIC (Women Infants Children)

Section 8

Pell Grant

School Breakfast/School Lunch Program

Federal Public Housing Assistance

Income Qualifications

For those individuals who are not on any of the approved Govt. Benefits Programs, you may apply for a FREE Smartphone under the Income Qualifications rule if you can show proof of the following;

Your (or your dependent’s) first and last name
Your annual income
To show documentation of income that does not cover a full year, such as current pay stubs, the documentation must cover three months in a row within the past twelve months

Document Examples:

Prior year’s state, federal, or Tribal tax return
Current income statement from your employer or a paycheck stub
A Social Security statement of benefits
Veterans Administration statement of benefits
Unemployment or Worker’s Compensation statement of benefits
Divorce decree, child support award, or a similar official document showing your income
A retirement/pension statement of benefits
Your (or your dependent’s) first and last name
Your annual income
To show documentation of income that does not cover a full year, such as current pay stubs, the documentation must cover three months in a row within the past twelve months

Here are the ways your household can qualify for the Affordable Connectivity Program:

Based on your household income
If you or your child or dependent participate in certain government assistance programs such as SNAP, Medicaid, WIC, or other programs
If you or anyone in your household already receives a Lifeline benefit
Note: You may qualify for the Lifeline Program through a participating provider’s existing low-income program. Visit our How to Apply page to learn more.

My Application is based on my income.

I am older than 18 years old.

I am the authorized person to make decisions for Internet services and to change the Internet Service Provider.

I agree that if I move I will provide my new address to my service provider within 30 days.

No one else is getting Affordable Connectivity Program benefits at my house right now.

I hereby certify that I have read this thoroughly and agreed to these disclosures.

I understand that agreeing to these terms and submitting this form is the equivalent of a legal signature.

Choose Your Smart Phone

Choose Your Cell Phones

If you are human, leave this field blank.

Questions About Our Program?

We’d love to hear from you! If you have any questions, or comments, or need more information, feel free to reach out.

Simply send us an email, and our team will get back to you as soon as possible.

Email TAL

Questions About Our Program?

We’d love to hear from you! If you have any questions, or comments, or need more information, feel free to reach out.

Simply send us an email, and our team will get back to you as soon as possible.

Email TAL