Lifeline and ACP Online Application
Please Fill Out Form Correctly To Avoid Delays
Name
*
First Name
Last Name
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Last Four of Social Security Number
*
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please select the program you are currently enrolled in (Select One):
*
Federal Public Housing Assistance (FPHA) or Section 8
Healthy Connections/ Select Health (Medicaid)
Supplemental Nutrition Assistance Program (SNAP/Food Stamps/Food Assistance)
Supplemental Security Income (SSI)
Veterans or Survivors Pension
Qualify through my Income
Signature
*
Submit
Should be Empty: