Centranet Lifeline Enrollment

1
Form Timestamp
Date
Month
Day
Year
5
1
2
3
4
5
6
7
8
9
10
11
12
Hour
38
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
PM
AM
PM
2
Name* This field is required.
First Name
Last Name
3
Centranet Account Number* This field is required.Service must be active with Centranet before applying for the Lifeline benefit.
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Email* This field is required.
example@example.com
6
Lifeline Application ID* This field is required.
7
Lifeline Application Date* This field is required.Please enter the date you applied for Lifeline
Date
Month
Day
Year
8
Do you qualify for Lifeline benefits through another person known as a Benefit Qualifying Person (BCP)?
YESNO
9
Full name of BCP
10
Please forward a copy of your approval email from USAC to info@centranetfiber.com or upload a copy here.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
11
Do you live on Tribal lands?* This field is required.https://www.lifelinesupport.org/wp-content/uploads/documents/get-lifeline/fcc_tribal_lands_map.pdf
YESNO
12
Are you transferring your Lifeline benefit from another internet provider?
YESNO
13
Are you also applying for ACP?
YESNO
14
Please select one qualifying government assistance program OR select that you qualify through your income.* This field is required.
Supplemental Nutrition Assistance Program (SNAP) (Food Stamps)
Supplemental Security Income (SSI)
Medicaid
Federal Public Housing Assistance (FPHA)
Veterans Pension or Survivors Benefit Programs
Bureau of Indian Affairs (BIA) General Assistance
Tribal Temporary Assistance for Needy Families (Tribal TANF)
Food Distribution Program on Indian Reservations (FDPIR)
Tribal Head Start
Eligibility Based on Income
15
Last Four Digits of Applicant's Social Security Number* This field is required.
16
Applicant's Date of Birth* This field is required.
Date
Month
Day
Year
17
Please review the following Lifeline Terms

https://www.centranetfiber.com/home/assistance-programs/lifeline

You will be asked to agree to these statements on the next page.
18
Agree to Lifeline Terms* This field is required.
I agree to all Lifeline Terms
19
Signature* This field is required.
Clear
Should be Empty: