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LifeLine Internet Benefit Application

Birthday
Month
Day
Year
Qualifying Benefit For LifeLine Credit
Snap/EBT
Medicaid/Medicare
SSI/SSDI
Federal Housing Assistance/HUD/Section 8

*"By submitting this form, you certify that:
All information provided is true and accurate to the best of your knowledge.
You authorize a Lifeline program representative to contact you via phone, email, or text to verify eligibility and complete enrollment.

 

Note: False information may result in disqualification from the program.

 

Questions? Call 

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