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LifeLine Internet Benefit Application

What is your Date of Birth?
Month
Day
Year
What qualifying benefits do you receive for the Lifeline Credit?*
Snap / EBT
Medicaid / Medicare
SSI / SSDI
Federal Housing / 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 email or phone call to verify eligibility and complete enrollment.

Questions? Call 888-977-2003

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