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LifeLine Internet Benefit Application

Birthday
Month
Day
Year
What qualifying benefits do you receive for the Lifeline Credit? (Select all that apply)*

*"By submitting this form, you certify that:
All information provided is true and accurate to the best of your knowledge.
You authorize a Lifeline program representative to contact you via phone, email, or text to verify eligibility and complete enrollment.

 

Note: False information may result in disqualification from the program.

 

 

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