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    This document contains a Washington certification form for the Lifeline assistance program, which provides discounted phone or internet service. It requests personal information from the applicant such as name, address, birthdate and last 4 digits of SSN to verify eligibility. The applicant must agree that they will only receive the Lifeline benefit for one service, understand program rules, and authorize the state to provide eligibility information to the service provider.

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    matty
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    This document contains a Washington certification form for the Lifeline assistance program, which provides discounted phone or internet service. It requests personal information from the applicant such as name, address, birthdate and last 4 digits of SSN to verify eligibility. The applicant must agree that they will only receive the Lifeline benefit for one service, understand program rules, and authorize the state to provide eligibility information to the service provider.

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    This document contains a Washington certification form for the Lifeline assistance program, which provides discounted phone or internet service. It requests personal information from the applicant such as name, address, birthdate and last 4 digits of SSN to verify eligibility. The applicant must agree that they will only receive the Lifeline benefit for one service, understand program rules, and authorize the state to provide eligibility information to the service provider.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    34 views1 page

    Form

    Uploaded by

    matty
    This document contains a Washington certification form for the Lifeline assistance program, which provides discounted phone or internet service. It requests personal information from the applicant such as name, address, birthdate and last 4 digits of SSN to verify eligibility. The applicant must agree that they will only receive the Lifeline benefit for one service, understand program rules, and authorize the state to provide eligibility information to the service provider.

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    © All Rights Reserved
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    of 1

    LIFELINE ASSISTANCE PROGRAM.

    WASHINGTON CERTIFICATION FORM

    PromoCode: Enrollment ID: 41443991

    Section 1 Date (MM/DD/YYYY): 05/06/2020


    Please make sure that you provide correct personal information. Your information will be validated against Public Records and any discrepancies could result in delays in your approval or rejection of
    service.

    1. PLEASE PRINT name and physical residence address of person verifying for assistance:
    SEXTON MATTY 5420 03/18/1983
    Legal Last Name Legal First Name MI SSN (Last 4) Birth Date (MM/DD/YYYY)

    2001 GREEN HOLLOW RD COLFAX 99111


    Street Address / Apt. Number (no PO BOX allowed) City Zip Code

    WA
    Address Line 2 State Contact Phone Number Email Address

    Mailing Address

    PO BOX 46 FAIRFIELD 99012 WA


    Mailing Address (PO Box allowed) Mailing Address 2 City Zip Code State

    Complete this part ONLY if your child or dependent is the Lifeline eligible applicant.

    First Name Last Name Birth Date (MM/DD/YYYY) SSN (Last 4)

    Your Plan Features

    Smartphone
    350 FREE monthly minutes & unlimited texts with 3GB/month of FREE
    data.

    *Unused balance will not carryover from month to month.

    Section 2
    This service is supported by Lifeline. Lifeline is a federal benefit that makes monthly telephone and broadband service more affordable for eligible households. Your
    household may receive the Lifeline benefit for telephone service OR broadband service, but not both. For Lifeline telephone service, your household may receive the Lifeline
    benefit for one mobile OR one fixed home telephone service, but not both. For Lifeline broadband service, your household may receive the Lifeline benefit for one mobile
    broadband OR one fixed broadband service, but not both. Your household may not receive the Lifeline benefit from more than one service provider. For the purpose of
    Lifeline, a household is an individual or any group of individuals who live together at the same address and share income and expenses. Lifeline is a non-transferable
    benefit. You may not transfer your Lifeline benefit to another person, even if he or she is eligible. You will lose your Lifeline benefit and may be prosecuted by the United
    States government if you violate the one-per-household rule or otherwise make false statements to receive the Lifeline benefit.
    We will validate your Lifeline eligibility with the National Verifier. By clicking the ‘I agree and E-sign’ button below, you are selecting SafeLink as your Lifeline provider. Once we
    receive confirmation of your eligibility from the National Verifier, we will automatically enroll you with SafeLink. If you currently receive Lifeline from another provider, your other
    Lifeline benefit will be terminated. You authorize SafeLink to communicate any information provided to the Universal Service Administrative Company for the purpose of
    providing Lifeline service to you.
    I understand this is a digital signature and is the same as if I sign my name with a pen.

    I authorize the Department of Social and Health Services/Economic Services Administration to provide a “yes” or “no” answer to the question of my receipt of
    Supplemental Nutrition Assistance Program (SNAP) or Medicaid benefits to SafeLink Wireless for the purpose of determining my initial eligibility or annual
    recertification for the federal Lifeline assistance program. My authorization is effective from the date of my signature below until I terminate my Lifeline
    service with SafeLink Wireless.

    By signing below, I separately affirm and agree to each of the above statements

    05/06/2020 14:54
    Printed Name Date (MM/DD/YYYY) PromoCode

    Applicant Signature E-Signature

    Have Questions?
    Call our Support phone number at: 1-800-SafeLink (723-3546).

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