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First Name
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Last Name
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Phone
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Email Address
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Address
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City
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Zipcode
Please enter your date of birth in the format DD/MM/YYYY. For example, if you were born in 2001, enter it as 01/01/2001.
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DOB
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4 Last SSN Number.
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Government benefiting.
E1 - Medicaid
E2 - SNAP
E3 - SSI
E4 - Federal Public Housing Assistance
E8 - BIA
E9 - TANF
E10 - FDPIR
E11 - Tribal Head Start
E13 - Based on Income
E15 - Veterans Pension and Survivors Benefit Program
E50 - School Lunch/Breakfast Program
E51 - Federal Pell Grant
E54 - WIC
Others
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I agree that if I move. I will give my service provider my new address within 30 days.
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I agree that my service provider can give the LifeLine Program Administrator all of the information I am providing. I understand that this information is meant to help run the LifeLine Program and that if I do not allow them to give it to the Administrator and I will not be able to receive LifeLine service.
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All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.
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My service provider may have to check whether I still qualify at any time. If I need to recertify (renew) my LifeLine benefit and I understand that I must respond by the deadline provided or I will be removed from the LifeLine Program.
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I agree to all of the above provided and disclosed terms.
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I understand that I am not allowed to receive multiple LifeLine Program benefits with the same or different providers AND I consent to enroll or transfer into the U2C Mobile LifeLine Program.
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I hereby certify that to the best of my knowledge. My household is not receiving a LifeLine service benefit and I would like to enroll for a LifeLine benefit with U2C Mobile LifeLine Powered by SafetyNet.
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