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 NameLast Name
Your Phone Number

Area CodePhone Number
Email
example@example.com
Your Address (Matching Your Service Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you currently have any services with Kaptel?
QUALIFY THROUGH A GOVERNMENT PROGRAM:
Check all programs or tribal-specific programs that you or someone in your household have:
Check all Tribal Specific programs that you or someone in your household have:
QUALIFY THROUGH YOUR INCOME:
Check this box ONLY if you do not qualify through a government program.
LIFELINE DOCUMENTATION

Visit and complete Lifeline's Verifying Service here: https://www.getinternet.gov/apply?id=nv_home&ln=RW5nbGlzaA%3D%3D

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
Should be Empty:

Lifeline Internet Qualification Form