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.

* DOB

Wrong SSN will not Qualify!

* 4 Last SSN Number.

* Government benefiting.

Acceptable documents include SNAP/EBT card, Medicaid letter, SSI award letter, etc.

* Upload Proof of Government Assistance

I agree that if I move. I will give my service provider my new address within 30 days.

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.

All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.

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.

I agree to all of the above provided and disclosed terms.

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.

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.