lifeline paper application

Paper Applications

Below is the application for those who are choosing to mail their Lifeline application. However, to speed things up, you can also enroll online!

DOWNLOAD THE PAPER APPLICATION
ENROLL ONLINE

If you are a resident in Oregon or Texas please download your state-specific application below. If you are a California resident you must Enroll online or with an agent.

What You Need to Enroll for
Lifeline Cell Phone Service:

Along with your application, send a copy of:

1) Your government issued photo ID or driver’s license.

2) An Eligibility Document.

IMPORTANT

  • – Documents must be dated within 12 months of application date.
  • – Must be your documents.
  • – Must show your name or your dependent’s name.
  • – Your name and address must match your state-issued photo ID, or your application will be turned down.

 

HOUSEHOLD WORKSHEET (IEH FORM)

Household Worksheet
Download English | Download Spanish

Oregon Household Worksheet
Download English | Download Spanish

Oregon Tribal Household Worksheet
Download English | Download Spanish

Your privacy is important to us.

You will be able to submit these documents as part of your application. Rest easy because your documents are always 100% protected under our Privacy Policy.

Click on your state to print a paper application to send in.

All NLAD states may enroll by mail using this application.

NLAD opt-out states – California*, Oregon, and Texas please use the links below.

*Service providers in California with broadband-only subscribers must use NLAD to enroll these subscribers.

HAVE YOU APPLIED THROUGH THE NATIONAL VERIFIER AND BEEN APPROVED AS ELIGIBLE?
If not, please go to the National Verifier at LifelineSupport.org for eligibility approval. You must submit your National Verifier application ID with your paper application prior to mailing.

  ID Guidelines

  • U.S. Driver License
  • Certificate of U.S. Citizenship
  • Certificate of Naturalization or Citizenship
  • U.S. Passport/U.S. Territory Passport
  • Foreign Passport
  • U.S. government, military, state or Tribal issued-ID, which includes date of birth and/or Social Security Number and/or Tribal ID
  • U.S. Military ID cards (active or reserve duty, dependent of a military member, retired member, discharged from service, medical/religious personnel)
  • Common Access Card (only if designated as Active Military or Active Reserve or Active Selected Reserve)
  • Military Discharge documentation, which includes date of birth and/or Social Security Number and/or Tribal ID
  • Northern Mariana Card
  • Permanent Resident Card
  • Permanent Resident Alien Card
  • Permanent Resident Re-Entry Permit
  • Temporary Resident Identification Card
  • Employment Authorization Card
  • Mexican Consular Card (Matricula Consular - 2006, 2014, 2015 and later versions)

 

*All forms of ID must be valid and used before expiration date.

Qualify by income and provide one of the following as proof.

  • Prior Year’s State, Federal or Tribal Tax Return
  • Unemployment/Workers' Compensation Benefits Statement
  • Divorce Decree or Child Support Documents
  • Veterans Administration Benefits Statement
  • Current Income Statement from Employer or Paycheck Stubs
  • Retirement/Pension Benefits Statement
  • Social Security Benefits Statement

Bureau of Indian Affairs General Assistance (BIA)

BIA Award letter, should contain the following basic information:

  • Name of the program,
  • Name of the beneficiary
  • Address of the beneficiary
  • Date of the award

Tribal Head Start

Head Start Award letter, should contain the following basic information:

  • Name of the program,
  • Name of the beneficiary
  • Address of the beneficiary
  • Date of the award

Tribally-Administered Temporary Assistance to Needy Families (TANF)

TANF Award letter, should contain the following basic information:

  • Name of the program,
  • Name of the beneficiary
  • Address of the beneficiary
  • Date of the award

Food Distribution Program on Indian Reservations (FDPIR)

Notice of Action (award letter) acknowledging eligibility for FDPIR benefits;

  • Name of the beneficiary;
  • The beginning and ending dates of the award or certification period; and
  • The telephone number of the Food Distribution Program office, and the name and address of the person to contact for additional information.

OR

FDPIR participation documents(e.g., a benefit card or copy of a benefit card);

  • Name of the beneficiary
  • The beginning and ending dates of the award or certification period; and
  • The telephone number of the Food Distribution Program office, and the name and address of the person to contact for additional information.

Lifeline Program

Due to sharing many of the same eligibility requirements those currently enrolled in the lifeline program may qualify for The Affordable Connectivity Program (ACP) also.

 

Medi-Cal / Medicaid

Program Approval Letter, Benefit Statement, or Verification of Coverage Letter, should contain the following basic information:

  • Name of the program or state equivalent,
  • Name of the beneficiary,
  • Address of the beneficiary, and
  • Date of the award

OR

Eligibility Screenshot or printout from an online portal or website tool, should contain the following basic information:

  • Name of the program or state equivalent,
  • Name of the beneficiary
  • Medical Identification number, OR
  • Case number,
  • Eligibility dates, OR
  • Current participation status

CalFresh / Food Stamps / SNAP

Program Approval Letter, Benefit Statement, or Verification of Coverage Letter, should contain the following basic information:

  • Name of the program,
  • Name of the beneficiary,
  • Eligibility dates, OR
  • Current participation status

OR

Eligibility Screenshot or printout from an online portal or website tool, should contain the following basic information:

  • Name of the program or state equivalent,
  • Name of the beneficiary,
  • Case number,
  • Eligibility dates, OR
  • Current participation status

Federal Veterans Affairs (VA) Veterans Pension and Survivors Benefit

Pension Grant Letter should contain the following basic information:

  • Participant’s name
  • Address
  • A decision about the participant’s monthly entitlement amount
  • Payment start date

Federal Public Housing Assistance (FPHA)

FPHA award letter should contain the following basic information:

  • Name of the program,
  • Date of the award,
  • Name of the beneficiary, and
  • Award amount.

Supplemental Security Income (SSI)

Approval Letter or Benefit Statement issued by the SSA or on SSA letterhead.

  • Consumer’s name
  • Date
  • Eligibility Date
  • Claim number OR Other consumer identification number
  • Payment amount

Medicaid / Medi-Cal

Program Approval Letter, Benefit Statement, or Verification of Coverage Letter should contain the following basic information:

  • Name of the program or state equivalent,
  • Name of the beneficiary,
  • Address of the beneficiary, and
  • Date of the award

OR

Eligibility Screenshot or printout from an online portal or website tool should contain the following basic information:

  • Name of the program or state equivalent,
  • Name of the beneficiary
  • Medical Identification number, OR
  • Case number,
  • Eligibility dates, OR
  • Current participation status

SNAP / Food Stamps / CalFresh

Program Approval Letter, Benefit Statement, or Verification of Coverage Letter should contain the following basic information:

  • Name of the program,
  • Name of the beneficiary,
  • Eligibility dates, OR
  • Current participation status

OR

Eligibility Screenshot or printout from an online portal or website tool should contain the following basic information:

  • Name of the program or state equivalent,
  • Name of the beneficiary,
  • Case number,
  • Eligibility dates, OR
  • Current participation status

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  Eligibility Documents

  • Current or prior year's statement of benefits from a qualifying state, federal or Tribal Program.
  • Notice letter of participation in a qualifying state, federal or Tribal Program.
  • Program participation documents.
  • Another official document evidencing the consumer's participation in a qualifying state, federal or Tribal Program.
  • Unemployment Documentation (notice of unemployment benefit payment or notice of successfully submitted application for unemployment benefits)
  • Copy of last year's State or Federal income tax return.
  • 3 consecutive months' worth of your most current pay stubs.
  • Social Security benefits statement. Veterans Administration benefits statement.
  • Retirement/Pension benefits statement.
  • Divorce decree or child support document.
  • Unemployment/Workers' Compensation benefits statement.

If you, or one of your dependents, participate in one of these programs, your household may be eligible for the federal government Lifeline supported benefits.

  Government Programs

Supplemental Nutrition Assistance Program (SNAP) Supplemental Security Income (SSI)
Medicaid Veterans Pension and Survivors Benefit
Federal Public Housing Assistance (FPHA) Food Distribution Program on Indian Reservations (FDPIR)
Tribally Administered TANF Bureau of Indian Affairs General Assistance
Tribally Administered Head Start (Meeting the income-qualifying standards of Head Start)

  ID Guidelines

  • U.S. Driver License
  • Certificate of U.S. Citizenship
  • Certificate of Naturalization or Citizenship
  • U.S. Passport/U.S. Territory Passport
  • Foreign Passport
  • U.S. government, military, state or Tribal issued-ID, which includes date of birth and/or Social Security Number and/or Tribal ID
  • U.S. Military ID cards (active or reserve duty, dependent of a military member, retired member, discharged from service, medical/religious personnel)
  • Common Access Card (only if designated as Active Military or Active Reserve or Active Selected Reserve)
  • Military Discharge documentation, which includes date of birth and/or Social Security Number and/or Tribal ID
  • Northern Mariana Card
  • Permanent Resident Card
  • Permanent Resident Alien Card
  • Permanent Resident Re-Entry Permit
  • Temporary Resident Identification Card
  • Employment Authorization Card
  • Mexican Consular Card (Matricula Consular - 2006, 2014, 2015 and later versions)

 

*All forms of ID must be valid and used before expiration date.