Lifeline Application - Virginia T-Mobile printable pdf download

Lifeline Application

Virginia

This signed Lifeline application (“Application”) is required to enroll you in T-Mobile’s Lifeline program in Virginia. This Application is

only for the purpose of verifying your eligibility for Lifeline and not for any other purpose. See next page for submission instructions.

T-Mobile’s applicable Terms and Conditions of service will also apply to existing or newly activated service (a copy may be obtained

by visiting ).

THINGS TO KNOW ABOUT THE LIFELINE PROGRAM

(1) Lifeline is a Federal benefit that is not transferable to any other person;

(2) Lifeline service is available for only one line per Household. A Household cannot receive benefits from multiple providers;

(3) A Household is defined, for purposes of the Lifeline program, as any individual or group of individuals living at the same

address that share income and expenses; and,

(4) Violation of the one-per Household rule is not permitted under federal rules and will result in the subscriber’s de-

enrollment from the program and possible criminal prosecution by the U.S. Government.

PERSONAL INFORMATION

First Name: _________________________ MI: _________ Last Name: ___________________ Date of Birth: _____/______/______

Last 4 Digits of Social Security Number: ___________________Contact Telephone Number: ________________________________

T-Mobile Number

: ___________________________ Email address: ___________________________________________

(if applicable)

Eligible Dependent(s): __________________________________________________________________________________________

I currently receive Lifeline benefits from another carrier and I request that T-Mobile submit a Benefit Transfer on my behalf. I

understand that I will only receive Lifeline benefits from T-Mobile and will lose my benefits from my current service provider.

Residential Address:

Must be a street address (not a P.O. Box) and your principal residence

Street Address: ____________________________________________________________________________ Apt: _______________

City: ______________________________________________________ State: _____________ Zip Code: _______________________

This address is:

Permanent Address

Temporary Address

If temporary, we may require your address to be certified or updated every 90 days

A shared, multi-Household residence

Provided by the state under the Address Confidentiality Program (ACP)

Billing Address:

Check here if the billing address is the residential address.

Billing Address may contain a P.O. Box

Street Address: ____________________________________________________________________________ Apt: _______________

City: ______________________________________________________ State: _____________ Zip Code: _______________________

ELIGIBILITY

(COMPLETE EITHER SECTION)

PROGRAM BASED PARTICIPATION

INCOME-BASED PARTICIPATION

_____ I hereby certify that I or my eligible dependent(s) qualify

_____

I hereby certify that my Household income is at or

to participate in at least one of the following

below 135% of the Federal Poverty Guidelines as

Initial

programs:

identified below. There are ______ members in my

(check all that apply)

Household.

(check box that applies)

Supplemental Security Income (SSI)

Member of Household

Household Income must be at

Supplemental Nutrition Assistance Program (SNAP) or Food

or below

Stamps

$16,038

Medicaid

$21,627

Federal Public Housing Assistance (FPHA) or Section 8

$27,216

Low Income Home Energy Assistance Program (LIHEAP)

$32,805

Temporary Assistance for Needy Families (TANF)

$38,394

National School Lunch Program’s free lunch program

$43,983

$49,586

$55,202

For every additional member of your Household, add $5,616

DOCUMENTATION REQUIREMENTS

YOU MUST PROVIDE COPIES OF ONE OR MORE OF THE FOLLOWING

YOU MUST PROVIDE COPIES OF ONE OR MORE OF THE FOLLOWING DOCUMENTS:

DOCUMENTS:

(1) prior year's state or federal tax return;

(1) current or prior year’s statement of benefits from qualifying

(2) Social Security, Veteran’s Administration, unemployment,

assistance program;

worker’s compensation, retirement or pension benefits

(2) notice or letter of participation in a qualifying assistance

statement;

program;

(3) current income statement from your employer or paycheck

(3) program participation documents; or,

stubs;

(4) official documents demonstrating receipt of benefits from a

(4) divorce decree or child support document.

qualifying assistance program.

SUBMITTED DOCUMENTS WILL NOT BE RETURNED

Lifeline Application - Virginia T-Mobile

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