Lifeline • Excess Telecom
Montrale Davis 434-329-1049
12 months $0
12 months $12 Co-Pay
One-time
Name
*
First Name
Last Name
Suffix
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of birth
*
SSN(Social Security) Last 4 Digits
*
You are eligible for the ACP if you (or someone in your household) participate in one of these programs:
*
SNAP
Medicaid
WIC
Supplemental Security Income (SSI)
Federal Public Housing Assistance (FPHA)
Veterans Pension and Survivors Benefit
Federal Pell Grant
Who receives government assistance?
*
Myself
Qualify Through Your Child or Dependent. Any member of your household can make your household eligible if they participate in one of the programs above. For example, if your child or dependent participates in the Free and Reduced-Price School Lunch Program or is enrolled in a USDA Community Eligibility Provision school, your household qualifies for the ACP benefit.
Fill out the additional information below ONLY if you are qualifying through another dependent in your household.
Name
First Name
Last Name
Date of birth
SSN(Social Security) Last 4 Digits
Benefit Award Letter(Only if requested)
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