Apply – Lifeline Expert

EligibilityConsent & DisclosureEnrollment Form

Step 1: Eligibility Check

Confirm your ZIP code and qualifying program before proceeding.

Language:

ZIP Code *

Qualifying Government Program *

Step 3: Lifeline Enrollment Application

⚠️ CRITICAL NOTICE: ALL information you provide below MUST be exactly identical to the information on file with your government benefit program.

👤 Beneficiary Personal Information

First Name *

Middle Name or Initial

Last Name *

Date of Birth *

Last 4 Digits of SSN *

📍 Primary Address

⛔ P.O. Boxes are NOT accepted. You must provide a physical residential address.

Street Address *

City *

State *

ZIP *

📍 Secondary / Mailing Address (if different)

Second Street Address

City

State

ZIP Code

🏠 Homeless Status

I am currently experiencing homelessness

🏠 Homeless Applicant Information

Please answer the following so we can process your application:

Where do you receive your mail?

Did you receive mail at the address on your government benefits application?

📞 Contact Information

Current Telephone Number *

Email Address *

A copy of your consent agreements will be sent here

📋 Program & Plan Selection

Qualifying Program *

Preferred Plan

Apply for Your Free Phone & Service

Step 1: Eligibility Check

Step 3: Lifeline Enrollment Application

🏠 Homeless Applicant Information

Application Submitted!

Ready to Get Your Free Phone?

Apply for Your Free Phone & Service

Step 1: Eligibility Check

Step 2: Consent & Disclosure Agreements

1. Lifeline Program Authorization & ETC Disclosure

2. One Benefit Per Household Rule

3. Eligibility Certification

4. Annual Recertification Requirement

5. Information Accuracy & Identity Verification

6. De-enrollment for Non-Use

7. Privacy & Data Use Consent

8. Electronic Signature & Email Consent

Step 3: Lifeline Enrollment Application

🏠 Homeless Applicant Information

Application Submitted!

Ready to Get Your Free Phone?