Lifeline Internet Form

Lifeline Internet Qualification Form

Kaptel is offering low-cost internet to qualifying households through Lifeline, a federal benefit that lowers the monthly cost of phone or internet service. Please fill out the form below and submit to see if you qualify.
Your Full Name *

First Name Last Name
Your Phone Number *

Area Code Phone Number
Email
example@example.com
Your Address (Matching Your Service Address) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Do you currently have any services with Kaptel? *

Yes No
QUALIFY THROUGH A GOVERNMENT PROGRAM:
Check all programs that you or someone in your household have:

Supplemental Nutrition Assistance Program (SNAP) (Food Stamps) Supplemental Security Income (SSI) Medicaid Federal Public Housing Assistance (FPHA) Veterans Pension or Survivors Benefit Programs
Check all Tribal Specific programs that you or someone in your household have:

Bureau of Indian Affairs (BIA) General Assistance Tribal Temporary Assistance for Needy Families (Tribal TANF) Tribal Head Start (only households that meet the income qualifying standard) Veterans Pension or Survivors Benefit Programs
QUALIFY THROUGH YOUR INCOME:
Check this box ONLY if you do not qualify through a government program.

Qualify by income
LIFELINE DOCUMENTATION

Visit and complete Lifeline's Verifying Service here: nationalverifier.servicenowservices.com/lifeline

Once approved, please add the verifying number you receive below.
(Please use the number that begins with Q. Your must provide your SSN to Lifeline to get the correct program and verification number.)
Lifeline Application ID Number *
QXXXXX-XXXXX
Check here *

I agree to give Kaptel permission to verify my application status with Lifeline for the purposes of this qualification.
Should be Empty:

Lifeline Internet Qualification Form