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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
*
Your email
Subscriber Personal Information EXACTLY as it is on the Lifeline Application (including capitalization, punctuation, etc.)
Application Enrollment ID:
B_ _ _ _ _ - _ _ _ _ _ or Q_ _ _ _ _ - _ _ _ _ _
*
Your answer
Last Name
*
Your answer
First Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Last 4 SSN
*
Your answer
Subscriber Person Address
Primary Address
*
Your answer
Address Line 2
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Mailing Address
If different from subscriber address
Address Line 1
Your answer
Address Line 2
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Subscriber Telephone Number
Phone Number
*
(xxx) xxx-xxxx
Your answer
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
Your answer
Last Name
Your answer
Last 4 SSN
Your answer
Date of Birth
MM
/
DD
/
YYYY
Benefit Person School District Name
*
Your answer
How do you qualify for the Lifeline Program
*
Choose
Medicaid
SNAP
Supplemental Security
Federal Public Housing Assistance
Head Start
Eligibility Based on Income
Veterans Pension or Survivors Pension
School Lunch/Breakfast Program
Federal Pell Grant
Substantial Loss of Income
Existing low-income program/Covid-19 program
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