Lifeline
Enroll Subscriber
Provide the Subscriber’s Full Name
First Name
Middle Name
Last Name
Provide the Subscriber’s Address
Primary Address
Apt, Unit, etc.
City
State
DC
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
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ZIP Code
Is the subscriber’s mailing address different from their physical address?
Yes
No
Provide the Subscriber’s Telephone Information
Phone No. is optional to verify
Service Type
Broadband
DSL
Satellite
Dial Up
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Service Initiation Date
mm/dd/yyyy
Phone Number
(xxx) xxx-xxxx
Lifeline Tribal Benefit?
Yes
No
Subscriber Eligibility Information
Eligible Program
E4 - Federal Public Housing Assistance (Section 8)
E1 - Medicaid
E2 - Supplemental Nutrition Assistance
E3 - Supplemental Security Assistance
E4 - Federal Public Housing Assistance (Section 8)
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IEH Certification Date
mm/dd/yyyy
Linkup Service Date
mm/dd/yyyy
Independent Economic Household?
Yes
No
Tribal Address?
Yes
No
Temporary Address?
Yes
No
Non-Deliverable Rural Address?
Yes
No
ETC General Use
Provide any additional comments or notes.
Reset
Confirm Link Up
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