Everyone applying for phone service with Lifeline benefits must complete and sign a Lifeline certification
form. The form is included as part of the on-line ordering process. For those who have ordered service over the
phone, you will need to submit a form before we can process your order.
Please click on your state below to get the form. Print the form and complete it.
After completing and signing the form, return it by one of the following methods.
Email it to us. If you can scan the document into your computer, you can
email it to us at email@example.com. Include your new account number in the subject
or body of the email. You could also take a high resolution picture of the document and email that to us.
Make sure the document is readable in the picture.
Fax it to 1-866-700-4736. Be sure to write your new account number at
the top of the form.
Text it to firstname.lastname@example.org. To text the document, you'll need to be able to
take a high resolution photo of it. The photo must be easily readable. When texting, enter the email address
email@example.com in the field where you would normally type the phone number you are texting to.
Mail it to the address on the form.
Download and Print Lifeline Form
If you placed your order on-line, you have already submited the Lifeline Certification Form. If you placed your order over the
phone, you will need to download the form here, fill it out and return it to us.
Mail-in forms are not available for all states. If a form is not
available for your state, you must use the on-line application