Safelink Application – Fill Out and Use This PDF

SECTION 1

Conirm your correct home address and select if you live at a temporary address. Provide mailing address if diferent.

Plan Features

Choose your plan (check one)

Local Calls

National Long Distance

Voice Mail

Nationwide Texting

Roaming at no Additional Cost

Free 911

411 Directory Assistance at no Additional Cost Carry-Over Minutes from Month to Month

100+ International Long Distance Destinations*

(Up to 1250 texts)

(Up to 1250 texts)

(Up to 1250 texts)

**

SECTION 2

*List of destinations available at www.safelink.com

**If you choose this plan, your unused minutes will be removed/wiped out and will not carry-over on your next monthly minutes delivery. However, if you purchase and redeem additional minutes cards, all unused minutes will carry over for three consecutive months.

Select ONE of the two options below (Proof of eligibility MUST be submitted for either option, name and address must match applicant).

OPTION

oSupplemental Nutrition Assistance Program (SNAP) Food Stamps*

oCash Assistance or Temporary Assistance for Needy Families (TANF) or Family Independence Program*

oMedicaid

oSupplemental Security Income (SSI)

oFederal Public Housing Assistance (Section 8)

oLow-Income Home Energy Assistance Program (LIHEAP)

oNational School Lunch Program’s (Free Lunch Program)

*Programs are validated by a state agency (No Proof required)

Qualify by checking the number of people in your family and your monthly income, attach proof of income such as last year’s Federal or State Income Tax return, a Social Security statement of beneit, a letter from your employer, pay stubs from 3 consecutive months, an Unemployment or Workmen’s Compen- sation statement of beneits, a Retirement/Pension statement of beneits or a divorce decree, child support award, or other oicial document containing income information. Provide Copies ONLY

Household Income MUST be at or below the guidelines in table below:

SECTION 3

You MUST check of (a) all statements, then Sign and Date application. (Your application cannot be approved without these items)

I certify under penalty of perjury to each of the following:

Boxes MUST be checked of

o I participate in the above designated qualifying program OR have income at or below the level speciied above.

oI understand that I must notify SafeLink® within 30 days if I no longer participate in the qualifying program or meet the income eligibility threshold, if I or another member of my household obtains Lifeline supported service from another carrier, or, for any other reason, I no longer qualify for Lifeline support.

oI understand I may be required to recertify my continued eligibility for Lifeline at any time, and failure to do so will result in termination of my Lifeline beneits.

o If I change my address, I will provide my new address to SafeLink® within 30 days.

oMy household will receive only one Lifeline beneit and to the best of my knowledge, my household is not already receiving a Lifeline service.

oThe information contained in this application is true and accurate to the best of my knowledge, and I acknowledge that providing false or fraudulent information to obtain Lifeline beneits is punishable by law.