Your name is:
Your telephone number is:
Social security number is:
Your date of birth is:
January 01, 1970
Your address is:
, , ,
Above address is your
Select any one of the applicable program from below to show that you, your dependent, or someone in your household qualifies for Lifeline. You can qualify through some government assistance programs or through your income (you do not need to qualify through both).
Federal Poverty Guidelines
If your income is at or below 135% of the federal poverty guidelines, as shown below, you can qualify for
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).
ETC is a lifeline supported service. Lifeline is federal benefit, and only eligible subscribers may enroll. Customers who willfully make false statements in order to obtain the benefit can be punished by fine for imprisonment or can be barred from the program. Lifeline is available for only one line per household. A household is defined as any individual or group of individual who live together at the same address and share income and expenses. A Household is not permitted to receive lifeline benefits from multiple providers. Violation of the one-per-household rule constitutes a violation of FCC rules, and will result in the customer's de-enrollment from Lifeline. Lifeline is a non-transferable benefit, and a customer may not transfer his or her benefit to another person.
Penalty of Perjury\nUnder title 18 U.S.C. § 1621, whoever willfully states as true any material matter which he does not believe to be true in a statement under penalty of perjury, is guilty of perjury and shall, except as otherwise expressly provided by law, be fined or imprisoned not more than five years, or both. I acknowledge that providing fraudulent documentation/information in order to receive assistance is punishable by law.