Are you applying for a phone, or Home internet?
Phone
Free internet
Do you currently have or ever had an ACP or Lifeline program?
*
Yes
No
Unsure
Full Name
*
First Name
Last Name
Suffix
How do you qualify?
*
EBT/ SNAP
WIC
Medicaid
Medicare
SSI
Veteran's Benefits
Income/ W2's
Proof of benefits or Income
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Last 4 of SSN
*
Birthday
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2 (apt, suite, unit, P.O. box)
City
State / Province
Postal / Zip Code
Are you interested in any other helpful services?
Discount on Dominion Energy
Solar Power for your home
Sign up for Medicaid
Life and Health Insurances
WOULD YOU BE PICKING UP DEVICE FROM OFFICE
YES I WOULD LIKE TO PICK UP MY DEVICE FROM OFFICE
NO
I WOULD LIKE TO RECEIVE MY DEVICE FROM AGENT
Other
WHO REFERED YOU?
ADRIAN BARNES
ANTONIO PRATCHER
BURGUNDY BROWN
CHRISTINA UPSHAW
CYNTHIA ROSARIO
JUSTICE WINTON
MADELINE LOPEZ-TAYLOR
MAISHA PHILLIPS
RAYMOND MASON
TANERA WILLIAMS
TRUMAN EDISON
Other
COMMENTS
Submit
Lifeline Phone Application
Please fill out the form below accurately to be approved for this FREE program
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