Identity Verification Form
What is your full legal name?
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First Name
Last Name(s) If you have multiple last names put them all in the box above.
What is your date of birth?
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Month
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Day
Year
Date Picker Icon
Current Address
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Street Number and Name
Apt, Unit, etc.
City
State / Province
Postal / Zip Code
Phone Number
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E-mail
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mrsample1@gmail.com
How do you want us to check your identity?
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Last 4 digits of your Social Security Number
Number on Tribal ID
Social Security Number(last 4 Digits only)
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If you selected the last four digits of your SSN, kindly complete this section.
Number on Tribal ID
If you selected the number on Tribal ID, please complete this section.
Identification Card (Valid State ID)
*
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Drivers License, Learners Permit, Passport (U.S. or foreign), Taxpayer identification Number (TIN), Other government ID (consumer ID, Birth certificate, or state photo ID card). The example Below serves as the optimal guideline for capturing the required image
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Can you show proof that you receive any government benefits? (Benefit Card, Benefit Letter, etc. )
*
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Although this is not required, submitting documents can significantly improve your eligibility for the Affordable Connectivity Program.
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I confirm that all the information provided above is accurate. However, inaccurate information may impact eligibility for the program.
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