Customer Details:
Ditch Your Monthly Cell Phone Bill
Did your phone get disconnected due to the ACP ending? Get reconnected Now and enjoy free Service by completing form below.
Full Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Last 4 of your SS#
*
Address
*
Street Address
Apt., Ste. or Unit#
City
State
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Select which government benefit you receive or select income if you don't receive any benefit.
*
Supplemental Nutritionist Assistant Program (SNAP)
Medicaid
Supplemental security income (SSI)
Federal Public Housing Assistance (Section 8)
Veterans Pension and Survivors Benefit
Income
File Upload
Browse Files
Drag and drop files here
Choose a file
Driver license or State Identification
Cancel
of
File Upload
Browse Files
Drag and drop files here
Choose a file
Supporting Documents
Cancel
of
How did you hear about us?
Submit
Follow Us
Should be Empty: