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  • Required Texas Application Form Lifeline Assistance Program: Section I

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    Lexi Sylvain
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    TEXAS LIFELINE assistance program application form PLEASE PRINT name and physical residence address of person applying for assistance: watson Last Name levi First Name n Middle Initial Home Phone Number Cell-Phone Number 605 WINTERFIELD DR APT 3734 Street / Apartment no. Contact Phone Number E-mail HUTTO City 587270563 Last 4 digits of SSN TX State 78634-5660 Zip Code 10 / 01

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    TEXAS LIFELINE assistance program application form PLEASE PRINT name and physical residence address of person applying for assistance: watson Last Name levi First Name n Middle Initial Home Phone Number Cell-Phone Number 605 WINTERFIELD DR APT 3734 Street / Apartment no. Contact Phone Number E-mail HUTTO City 587270563 Last 4 digits of SSN TX State 78634-5660 Zip Code 10 / 01

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    16 views1 page

    Required Texas Application Form Lifeline Assistance Program: Section I

    Uploaded by

    Lexi Sylvain
    TEXAS LIFELINE assistance program application form PLEASE PRINT name and physical residence address of person applying for assistance: watson Last Name levi First Name n Middle Initial Home Phone Number Cell-Phone Number 605 WINTERFIELD DR APT 3734 Street / Apartment no. Contact Phone Number E-mail HUTTO City 587270563 Last 4 digits of SSN TX State 78634-5660 Zip Code 10 / 01

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    of 1

    Enrollment Number: 6542738

    REQUIRED TEXAS APPLICATION FORM LIFELINE ASSISTANCE PROGRAM


    SECTION I
    Date: 05/21/2011

    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: watson Last Name levi First Name n Middle Initial

    Home Phone Number

    Cell-Phone Number 605 WINTERFIELD DR APT 3734 Street / Apartment No.

    Contact Phone Number

    sharronwatson25@yahoo.com E-mail HUTTO City 587270563 Last 4 digits of SSN TX State 78634-5660 Zip Code 10/01/1966 Birth Date
    250 Free Monthly Minutes

    Plan Features Choose your plan (check one)

    68 Free Monthly Minutes

    125 Free Monthly Minutes

    Local calls National long distance Voicemail Nationwide text Roaming at no additional cost Free 911 411 Directory Assistance* Carry-over minutes from month to month 100+ international long distance destinations

    (0.3 minutes per text)

    (1 minute per text)

    (1 minute per text)

    **

    *Minutes can be used for 411 calling at no additional cost. **If you choose this plan, 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):

    Federal Public Housing Assistance / Section 8 Health Benefit Coverage under Children's Health Insurance Plan (CHIP) Low Income Home Energy Assistance (LIHEAP) Medicaid Supplemental Nutrition Assistance Program (Food Stamps) Supplemental Security Income (SSI) 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.
    Do not mail this form; this is only for your records. A pre-filled application will be mail to you shortly. Remember you MUST sign and return your application along with copies of your proof of Program participation or your income level, to complete the Application Process.

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