®
Enrollment Number: 4371366
REQUIRED MICHIGAN APPLICATION FORM LIFELINE ASSISTANCE PROGRAM SECTION I
Date: 09/02/2010
Please make sure that you provide correct personal information. Your information will be validated against Public Records and any discrepancies could result in delays in your application approval.
1. PLEASE PRINT name and physical residence address of person applying for assistance: randall Last Name 2694199579 Cell-Phone Number 1114 10TH AVE S Street / Apartment No. jacqui First Name 9065537095 Contact Phone Number 9062410212 l Middle Home Phone Number Initial
[email protected] E-mail ESCANABA City 2453 Last 4 digits of SSN MI State 49829-3108 Zip Code 05/17/1970 Birth Date 250 FREE monthly minutes
Talk Minutes
Choose your plan (check one) Program features (information only) Carry-Over minutes from month to month 100+ International long distance destinations Text Messaging Voicemail/Caller ID/Call waiting
68 FREE monthly minutes
International Calling & Texting
125 FREE monthly minutes
Carry-Over Minutes
YES YES YES (0.3 minutes per text) YES
YES NO YES (1 minute per text) YES
NO* NO YES (1 minute per text) YES
*If you choose this program, all unused minutes (including purchased cards and free minutes) will be removed/wiped out and will not carry-over on your next monthly minutes delivery.
SECTION II
I hereby certify that I participate in at least ONE of the following public assistance programs (select just ONE program from the list): Medicaid Supplemental Nutrition Assistance Program (Food Stamps) Temporary Assistance to Needy Families (TANF) Supplemental Security Income (SSI) National School Lunch (free program only) Low Income Home Energy Assistance (LIHEAP) Federal Public Housing Assistance/Section 8
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Please make sure that you complete SECTION III on next page
SECTION III
PLEASE READ AND SIGN THE FOLLOWING:
Penalty of Perjury Under title 18 U.S.C. § 1621, whoever willfully states as true any material matter which he does not believe to be true in a statement under penalty of perjury, is guilty of perjury and shall, except as otherwise expressly provided by law, be fined or imprisoned not more than five years, or both.
I certify under penalty of perjury that: · · I am eligible for and currently receive benefits from the public assistance program(s) as identified herein. I do not currently receive Lifeline support for a land or wireless line serving my residential address, listed in page one of this application, and no other resident at my residential address participates in the Lifeline program; otherwise I agree to cancel my current household Lifeline support provider in favor of SafeLink Wireless ®. I am head of household and I am not claimed as a dependent on someone else’s federal or state tax return. I will notify SafeLink Wireless® when I no longer qualify for any of the public assistance programs identified herein by calling 1-800-SafeLink (723-3546) I will notify SafeLink Wireless® of any change of address by calling 1-800-SafeLink (723-3546) The information contained on this form is true and correct to the best of my knowledge and belief.
· · · ·
I authorize SafeLink Wireless® or its duly appointed representative to access any records required to verify my statements herein and to confirm my continued eligibility for Lifeline assistance. I also authorize social service agency representatives to discuss with and/or provide information to SafeLink Wireless® verifying my participation in benefit programs that qualify me for the Lifeline assistance. I understand that completion of this application does not constitute immediate approval for Lifeline. By signing below, I acknowledge that providing fraudulent documentation/information in order to receive assistance is punishable by law. Printed Name _____________________________________ Applicant Signature ___________________________________ Date _________________
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Amazon. com Privacy Notice Amazon. com knows that you care how information about you is used and shared, and we appreciate your trust that we will do so carefully and sensibly. This notice describes our privacy policy. By visiting Amazon. com, you are accepting the practices described in this Privacy Notice. What Personal Information About Customers Does Amazon. com Gather? The information we ...
Privacy Law Please check this box if you would like to receive pre-recorded special offers for SafeLink Customers and promotional offers from TracFone at the Home Telephone number provided in the Contact information.
Please return information to: SAFELINK WIRELESS ® PO Box 220009 Milwaukie OR 97269-0009 OR Fax application to: 1-866-902-5756 For questions concerning Lifeline, please call SafeLink Wireless® business office at 1-800-SafeLink (723-3546)