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?*

YesNo
QUALIFY THROUGH A GOVERNMENT PROGRAM:
Check all programs or tribal-specific programs that you or someone in your household have:*

Supplemental Nutrition Assistance Program (SNAP) (Food Stamps)Supplemental Security Income (SSI)MedicaidFederal Public Housing Assistance (FPHA)Veterans Pension or Survivors Benefit ProgramsNone of the above
Check all Tribal Specific programs that you or someone in your household have:*

Bureau of Indian Affairs (BIA) General AssistanceTribal Temporary Assistance for Needy Families (Tribal TANF)Food Distribution Program on Indian Reservations (FDPIR)Tribal Head Start (only households that meet the income qualifying standard)None of the above
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: 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*

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