Pre-qualification Form
Please make sure that the information below matches the information used to receive your Government benefits!
Email
*
example@example.com
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address (Must match benefits)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
*
-
Month
-
Day
Year
Date
Last 4 digits of Social Security number
*
Have you received a free government device in the past 12 months?
*
YES
NO
Which government benefit do you receive?
*
Free or reduced school meals
Medicaid, WIC, EBT, SNAP
SSI, Federal Public Housing Assistance
Lifeline
Your household income is at or below a certain amount. (e.g. $55,500/year for a family of four, $27,180/year for an individual).
Other
If approved, can you provide PROOF of your benefits?
*
YES
NO
If approved, are you able to provide the $20 activation fee?
*
YES
NO
Signature
*
Submit
Submit
Should be Empty: