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SECTION II
I hereby certify that I participate in at least ONE of the following public assistance programs (select just ONE
program from the list):
Please make sure that you complete SECTION III on next page
SECTION III
PLEASE READ AND SIGN THE FOLLOWING:
Penalty of Perjury
Under title 18 U.S.C. § 1621, whoever willfully states as true any material matter which he does not believe to be
true in a statement under penalty of perjury, is guilty of perjury and shall, except as otherwise expressly
provided by law, be fined or imprisoned not more than five years, or both.
I authorize SafeLink Wireless® or its duly appointed representative to access any records required to
verify my statements herein and to confirm my continued eligibility for Lifeline assistance. I also
authorize social service agency representatives to discuss with and/or provide information to SafeLink
Wireless® verifying my participation in benefit programs that qualify me for the Lifeline assistance. I
understand that completion of this application does not constitute immediate approval for Lifeline.
Privacy Law
Please check this box if you would like to receive pre-recorded special offers for SafeLink Customers
and promotional offers from TracFone at the Home Telephone number provided in the Contact
information.
For questions concerning Lifeline, please call SafeLink Wireless® business office at
1-800-SafeLink (723-3546)