ACP/Lifeline FREE Phone
ONE Phone and/or Tablet Per Household
Product(s) Applying For
Please Select
FREE Phone
$30 Tablet
FREE Phone & $30 Tablet
Tablets are $30 & Include FREE DATA* or WIFI Only
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
LAST 4 Of Your Social Security Number
If Left Blank We Will Call You To Complete
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Select A Federal Program You Are A Member Of
*
Please Select
SNAP
MEDICAID
TANF
WIC
SSI
SECTION 8
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Sign Up Your Dependent
LEAVE BLANK IF No DEPENDENT
Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
LAST 4 Of Your Dependents SSN
If Left Blank We Will Call You To Complete
Select A Federal Program You Are A Member Of
Please Select
SNAP
MEDICAID
TANF
WIC
SSI
SECTION 8
Back
Next
OPTIONAL Things To Submit
Upload Your ID
Browse Files
Drag and drop files here
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of
OR Take A Photo of Your ID
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