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Date of birth*

Select Government Benefit*

Qualify through your income:

Or

Including you, how many people live in your household? (check one)

Is your income the same or less than the amount listed for your state and household size? (only check yes or no next to your household size)

	All 48 States, DC, and Territories (not Alaska and Hawaii)	Alaska	Hawaii
1	$20,331	$25,394	$23,369	Yes No
2	$27,594	$34,479	$31,725	Yes No
3	$34,857	$43,565	$40,082	Yes No
4	$42,120	$52,650	$48,438	Yes No
5	$49,383	$61,736	$56,795	Yes No
6	$56,646	$70,821	$65,151	Yes No
7	$63,909	$79,907	$73,508	Yes No
8	$71,172	$88,992	$81,864	Yes No
If more than 8, add this amount for each extra person:	Add $7,263	Add $9,086	Add $8,357	Yes No

Qualifying Through Child or Dependent

Qualifying Child First Name*

Middle Initial

Qualifying Child Last Name*

Suffix

Date of birth?*

SSN (Last 4 digits)*

Click to add government ID ( not required )

Upload Award Letter* Click here to add your Award Letter (Proof of Benefit).

Click to add Military ID ( not required )

Click to add Passport Photo( not required )

Click to add Taxpayer Identification Number ( not required )

Click to add Other Goverment ID ( not required )

Applicant Address

Residence Address*

The above address is your: Permanent Address Temporary Address

What is your shipping address? (Only fill this out if it is not the same as your home address.)

Shipping Street Address

Shipping Apartment # or Suite #

Shipping City

Shipping State

Shipping Zip Code

Agreement

Confirm and sign your application

I agree, under penalty of perjury,to the following statements:
(You must initial next to each statement.)
Initial
I (or my dependent or other person in my household) currently get benefits from the government program(s) listed on this form or my annual household income is 135% or less than the Federal Poverty Guidelines (the amount listed in the Federal Poverty Guidelines table on this form).
Initial
I agree that if I move I will give my service provider my new address within 30 days.
Initial
I understand that I have to tell my service provider within 30 days if I do not qualify for Lifeline anymore, including:
1.) I, or the person in my household that qualifies, do not qualify through a government program or income anymore.
2.) Either I or someone in my household gets more than one Lifeline benefit (including more than one Lifeline broadband internet service, more than one Lifeline telephone service, or both Lifeline telephone and Lifeline broadband internet services).
Initial
I know that my household can only get one Lifeline benefit and, to the best of my knowledge, my household is not getting more than one Lifeline benefit.
Initial
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 Lifeline Program Administrator, I will not be able to get Lifeline 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 a Lifeline Program benefit.
Initial
All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.
Initial
I know that willingly giving false or fraudulent information to get Lifeline Program benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program.
Initial
My service provider may have to check whether I still qualify at any time. If I need to recertify (renew) my Lifeline benefit, I understand that I have to respond by the deadline or I will be removed from the Lifeline Program and my Lifeline benefit will stop.
Initial
The certification below applies to all consumers and is required to process your application. I was truthful about whether or not I am a resident of Tribal lands, as defined in section 2 of this form

Sign by typing your name below:

I agree to the terms of service and privacy policy. Verify benefits and delivery through SMS I acknowledge that my PII will be transferred to NLAD to complete my Lifeline enrollment.

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Qualify through your income:

Or

Applicant Address

Agreement

Confirm and sign your application