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
LIFELINE DOCUMENTATION

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

Once approved, please add the verifying number you receive below.
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