Lifeline Program Renewal Form PDF Details

The Lifeline Program Renewal Form is a document that must be completed by all subscribers of the Lifeline program in order to renew their participation in the program. The form asks for personal information, as well as required certifications and signatures. It is important to complete the form accurately and completely, in order to avoid any delays or interruptions in your service. You can find more information about the Lifeline Program Renewal Form on our website. We recommend that you read through all of the instructions before you begin completing the form. If you have any questions, please don't hesitate to contact us.

Here is some specifics that may help you find out how much time it will take to finalize the lifeline program renewal form.

Form NameLifeline Program Renewal Form
Form Length4 pages
Fillable fields0
Avg. time to fill out1 min
Other nameswww californialifeline com, ca lifeline renewal, californialifeline renewal, www californialifeline com renewal

Form Preview Example

Federal Lifeline Program


To continue receiving your discounts with

federal Lifeline renew before...

RESPONSE DATE: 02/17/2014

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Keep this sheet for your records.

You can renew online at

using the PIN below


There are two ways for you to renew your telephone discounts from this federal program:


For the quickest processing, renew online

Mail to:


California LifeLine Administrator

using your PIN.

P.O. Box 8417,


Westminster, CA 92684

Page 1 of 6

Continue your discounts...RENEW today!

Here’s how:

Step 1

Step 2

Step 3

Step 4

Final Step

Check that your personal information is correct.

Is your household already getting the federal Lifeline discounts?

Are you a Program-Based participant?

Are you an Income-Based participant?

Submit your form online or by mail before the response date.

You do not need to provide any supporting documentation with your renewal form.

Step 1

Check your name, address, and phone number.

Call your phone company to report any mistakes within 30 days. The phone company will fix them. Corrections on this sheet will NOT be accepted.

Billing Address

Participant’s Phone Number: 555-555-5555




Anniversary Date:04/17/2014

APT. 1




Permanent Service Address



Carrier’s Phone Number: 888-888-8888





Page 2 of 6

Federal Lifeline Program




































RESPONSE DATE: 02/17/2014




























Step 2

By printing my initials here, I certify that no one else in my household is receiving

























federal Lifeline discounts with my current phone company or another phone company





































(including California LifeLine for phone service).


































































































Step 3

PROGRAM-BASED: Are you or is anyone in your household, including kids, enrolled in any of the programs

















listed below? If YES, fill in the bubble with a blue or black pen next to all of the programs in which you or any









household member(s) are enrolled. Fill in bubble completely. Sample:



































































Women, Infants, and Children Program (WIC)


Supplemental Security Income (SSI) National School Lunch Program (NSLP)

Low Income Home Energy Assistance Program (LIHEAP)

CalFresh, Food Stamps, or Supplemental Nutrition Assistance Program (SNAP)

Federal Public Housing Assistance or Section 8

Tribal TANF

Head Start Income Eligible (Tribal Only) Bureau of Indian Affairs General Assistance

Food Distribution Program on Indian Reservations (FDPIR)

Temporary Assistance for Needy Families (TANF), California Work Opportunity and Responsibility to Kids (CalWORKs), Stanislaus Work Opportunity and Responsibility to Kids (StanWORKs), Welfare-to-Work (WTW), or Greater Avenues for Independence (GAIN)

STOP If you filled in any bubble on Step 3, skip Step 4.

Step 4

INCOME-B SED: Is your household’s total annual gross income at or less than the annual income limits? Check the Income Table in the Eligibility Guidelines.

How many people (adults and kids) are in your household?

Adults (18 and over)





Kids (under 18)










What is your household’s total annual gross income? (Round to whole dollars.)




Check the Income Calculator in the Eligibility Guidelines.



Turn Over

Page 3 of 6

Did You Remember To:

Call your phone company within 30 days to report any mistakes you see in Step 1.

Print your initials in Step 2.

Use blue or black pen to fill out your form.

Print and SIGN your name below.

For faster processing, apply online at using your PIN.


REMOVE ME - Fill in the bubble if you believe you Do Not Qualify for federal Lifeline and/or want to STOP getting the discounts.

SIGN AND PRINT YOUR NAME - By signing below in compliance with federal and state government rules, I certify, under penalty of perjury, that giving false or fraudulent information is punishable by law, that my household is qualified for the discounts, that my household will not be getting more than one discount, that the service address is my principal residence, that I am not claimed as a dependant on another person’s tax return, that I understand the notification rules, that I must renew my discounts annually, that if I do not renew I will lose the discounts, and that the information in this form is true and correct. I agree to inform my phone company or the California LifeLine Administrator within 30 days if I change my service address, if I no longer qualify for the federal Lifeline discounts, or if my household is getting more than one discount. I understand and agree that I will be penalized if I do not follow these notification rules. I acknowledge and give my consent for the California LifeLine dministrator to share my information in this form to the Universal Service Administrative Company and/or its agents. Legal Guardians or people with Power of Attorney are allowed to sign this form.

Participant’s Signature (REQUIRED)



Today’s Date:























































Fill in this bubble if signed by a Legal Guardian or a person with Power of Attorney.














































Participant’s Date of





The LAST 4 digits of the Participant’s Social Security Number (REQUIRED):

Last 4 digits

Participant’s First and Last Name (REQUIRED: Must match the name from Step 1 under Permanent Service Address)

(Optional) Fill in the bubble next to your choice for future notifications.

Standard Print

Large Print


FD EN 10 #R RN 1.0 08-12

Page 4 of 6

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