ACP / Lifeline application for Online.tsg

ACP / LifeLine Benefits Campaign Program
Birth Date*

MonthDayYear
Name:*

First NameLast Name
Phone Number:*

Area CodePhone Number
E-mail Address:*
Who receives the qualifying benefits?*

MYSELFI have a dependent with benefits (child, grandchild, etc)
If you are using a dependent's information to qualify, please put their information in the next three information fields. If you are using your own benefits please skip the dependent fields and continue with the application.
Dependent Full Name:

First NameLast Name
Dependent Birth Date

MonthDayYear
Dependent Last 4 of SS# :
Only last four of social security #
Applicant Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last 4 of SS# :*
Only last four of social security #
Approved Benefits *

Medicaid (State Hlth Ins)Public Housing - Sec 8SS DisabilityRetirement BenefitsProof of IncomeFood Stamps
Upload Proof of Benefit/s:*

Upload a File
Copy of benefit card, SS Income Letter, Awards Letter, W-2, 1099, AGI Line from Tax return, etc. Cancelof
Upload Unexpired DL / ID:*

Upload a File

Cancelof
Shipping Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you were referred to us; please let us know who or what agency referred you to us so we can thank them. Blessings to you...
Enter name, agency, etc.
Please verify that you are human*
Should be Empty:

ACP / LifeLine Benefits Campaign Program