LIFELINE application Updated 08.30.24

LIFELINE Benefits Application

Lifeline Program
Complete the form below as accurately as you can. Make sure your address, name and information is correctly spelled. We must also have a verifiable email address.

You are applying for a Lifeline Program Device if for some reason you do not qualify for the device we will process your application as a SIM only.
Phone Number*
Complete with area code
Name:*

First NameLast Name
Unexpired ID or DL:*

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Cancelof
E-mail Address:*
Make sure this is a verifiable email
Applicant Address:*

Street Address

Apt #, Suite #, etc.

CityState / Province

Postal / Zip Code
Last 4 of SS# :*
Only last four of social security #
Qualifying Benefits:*
Please upload your proof of benefit letter or statement

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Make sure it hasn't expired Cancelof
Shipping Address: Please make sure to use a good address for us to ship your device.*

Street Address

Apt #, Suite #, Etc

CityState / Province

Postal / Zip Code
I agree to the Terms and Conditions and Privacy Policy (refer to website)I acknowledge that my PII will be transferred to NLAD to complete my enrollment.I consent to my electronic signature be used to complete the required documentation to enroll in the Lifeline Program.
Sign by Typing your name below
If you are only approved for a SIM only activation; please provide your current IMEI# so we can verify that it will be compatible.
IMEI# --- you can retrieve your IMEI# from your device by entering *#06# and choose the first IMEI#
Please verify that you are human*
Should be Empty:

LIFELINE Benefits Application