AFFORDABLE CONNECTIVITY PROGRAM
Please submit your enrollment information. This information MUST match your Verification information EXACTLY (including capitalization, punctuation, etc.)
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Email *
Subscriber Personal Information EXACTLY as it is on the Lifeline Application (including capitalization, punctuation, etc.)
Last Name *
First Name *
Date of Birth *
MM
/
DD
/
YYYY
Last 4 SSN *
Subscriber Person Address
Primary Address *
Address Line 2
City *
State *
Zip Code *
Mailing Address
If different from subscriber address
Address Line 1
Address Line 2
City
State
Zip Code
Subscriber Telephone Number
Phone Number *
(xxx) xxx-xxxx
Benefit Person Information
If the subscriber information is not the same as the household member who qualifies for this benefit, please provide the information below.
First Name
Last Name
Last 4 SSN
Date of Birth
MM
/
DD
/
YYYY
Benefit Person School District Name *
How do you qualify for the Lifeline Program *
A copy of your responses will be emailed to the address you provided.
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