Fillable APPLICATION FORM – LIFELINE / LINK-UP ASSISTANCE PROGRAMS

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APPLICATION FORM – LIFELINE / LINK-UP ASSISTANCE PROGRAMS

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The APPLICATION FORM – LIFELINE / LINK-UP ASSISTANCE PROGRAMS form is 2 pages long and contains:

  • 0 signatures
  • 19 check-boxes
  • 33 other fields

Country of origin: OTHERS
File type: PDF

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Please make sure that you provide correct personal information. Your information will be validated against Public Records
and any discrepancies could result in delays in your approval or rejection of service.
1. PLEASE PRINT name and physical residence address of person verifying for assistance:
Legal Last Name
Legal First Name
Middle Initial
Last 4 digits of SSN
Street Address / Apt. Number (no PO BOX allowed)
Birthday
Check here if your
address is temporary
Contact
Phone Number
Email Address
City
Zip Code
State
Choose your plan (check one):
All programs feature Local Calls, National Long Distance, Voicemail, Nationwide Text, Roaming at no Additional Cost, Free 911,
411 Directory Assistance at no Additional Cost. The 68 minutes plan includes 100+ International Long Distance Destinations. The
68 and 125 minutes plans feature carry-over minutes from month to month. You can send or receive unlimited text messages per
month with any plan. The 250 minutes plan will not carry-over the minutes on your next monthly minutes delivery. However, if you
redeem additional minutes cards, all unused minutes will carry-over for three consecutive months.
125 Free
Monthly Minutes
68 Free
Monthly Minutes
250 Free
Monthly Minutes
(unlimited text messages)
(unlimited text messages)
(unlimited text messages)
125 Free
Monthly Minutes
I hereby certify that I participate in at least ONE of the following public assistance programs (select just ONE program):
Temporary Assistance for Needy Families (TANF) or Family
Independence Program (*)
Supplemental Nutrition Assistance Program (SNAP) Food Stamps (*)
Supplemental Security Income (SSI)
Federal Public Housing Assistance (Section 8)
Low-Income Home Energy Assistance
Program (LIHEAP)
National School Lunch Program's
(free lunch program)
Medicaid
If you receive assistance from one of the programs with (*) your eligibility will be validated against the State agency and no
proof is necessary. If you have been recently approved to receive the program and want to avoid delays, you can submit proof
at the end of the enrollment process (if presented the option) or by visiting our main page in the section (Already a Customer).
Remaining programs require proof of participation such as, an award letter from SSA or State agency stating that you receive
the benefit, or similar official document. Provide Copies ONLY.
SafeLink is a Lifeline supported service. Lifeline is a 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 or 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 individuals 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.
Promo Code:
Section 2
Enrollment ID:
Section 1
Date:
Complete this part ONLY if your child or dependent is the beneficiary of the qualifying program.
First Name
Last Name
Last 4 Digits of SSN
Birth Date (MM/DD/YYYY)
Mailing Address
Mailing Address (PO BOX allowed)
Mailing Address 2
City
Zip Code
State
LIFELINE ASSISTANCE PROGRAM
MICHIGAN CERTIFICATION FORM
You MUST place a check mark ( ) next to each statement, then Sign and Date below (your application cannot be
approved without these items).
I certify under penalty of perjury to each of the following:
1. I participate in the above designated qualifying program.
2. I understand that I must notify SafeLink within 30 days if I no longer participate in the qualifying program, if I or another
member of my household obtains Lifeline supported service from another carrier, or, for any other reason, I no longer
qualify for Lifeline support.
3. I understand I may be required to recertify my continued eligibility for Lifeline at any time, and failure to do so will result in
termination of my Lifeline benefits.
4. If I change my address, I will provide my new address to SafeLink within 30 days.
5. I understand that my household may receive only one Lifeline supported service. My Household does not currently
receive Lifeline Service OR my household currently receives Lifeline Service from another carrier and I authorize SafeLink
to transfer my Lifeline benefit to SafeLink and I understand this will terminate my Lifeline benefits with my existing carrier.
6. The information contained in this application is true and accurate to the best of my knowledge, and I acknowledge that
providing false or fraudulent information to obtain Lifeline benefits is punishable by law.
I authorize SafeLink Wireless or its duly appointed representative to: (1) access any records required to verify my
statements herein; (2) to confirm my continued eligibility for Lifeline assistance; (3) to update my address to proper mailing
address format; (4) to provide my name, telephone number, and address to the Universal Service Administrative Company
(USAC) (the administrator of the program) and/or its agents for the purpose of verifying that I do not receive more than one
Lifeline benefit; and (5) authorize social service agency representatives to discuss with and/or provide information to
SafeLink Wireless verifying my participation in benefit programs that qualify me for Lifeline assistance.
By signing below, I separately affirm and agree to each of the above statements
Printed Name
Date
Applicant Signature
E-Signature
Referred by a Friend
Referred By A Friend
Customer’s First Name
Customer’s Last Name
SafeLink Phone Number
Please check this box if you would like to receive pre-recorded special offers for SafeLink customers and promotional offers
from TracFone at the home telephone number provided in the contact information.
Please Return to
Mail Application: SafeLink Wireless
PO Box 220009
Milwaukie, OR 97269-0009
Or Fax Application: 1 (866) 902-5756
For questions concerning Lifeline, please call SafeLink
Wireless business office a 1 (800) SafeLink (723-3546)
Section 3
Promo Code
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APPLICATION FORM LIFELINE LINK-UP ASSISTANCE PROGRAMS

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Completed 15 February 2021

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