SCROLL TO REVIEW AND SIGN YOUR APPLICATION

To apply for the Lifeline Benefit, each section of this form must be completed, initial all agreement statements, and electronically sign the last section.

let's start with your personal information

What is your full legal name?

The name you use on official documents, like your Social security Card or State ID. Not a Nickname.

* Mandatory fields

First Name *

Suffix

Middle Initial

Last Name *

DOB

SSN (Last 4 digits) *

Drivers License # / Government ID *

What is the best way to reach you?

Email

Phone

Text Message

Mail

Contact Phone *

Who received government assistance? (SNAP, Medicaid, etc)

Myself

Somebody else in household

What is your home address?

Applicant Address/Service Address ( PO BOX is not allowed)

Address *

Address 2

Zipcode *

City *

State *

The above address is your *

Permanent

Temporary

Is Your Billing/Shipping address the same as the service address? *

Yes

No

Q1

Do you live with another adult?

Adults are people who are 18 years old or older, or who are emancipated minors. This can include a spouse, domestic partner, parent, adult son or daughter, adult in your family, adult roommate, etc.

No

Yes

Qualify for Lifeline Benefit

Please select a program below to show you, your dependent or someone in your household qualifies for the Lifeline Benefit. You can qualify for the Lifeline Benefit by showing that you already participate in one of the government assistance programs below. If you do not currently participate in one of the programs listed, you may be able to qualify based on income. You may be required to show proof of your participation in the program you choose or show proof of income.

Program Name

PENALTY OF PERJURY

PLEASE READ AND INITIAL THE FOLLOWING. BY SIGNING & INITIALING BELOW, YOU ARE AGREEING TO THE FOLLOWING PROGRAM RULES:

Terms and Conditions

By my signing the FCC application, I agree to accept True Wireless, Inc Terms & Conditions located at https://gotruewireless.com/TermsConditions.php

Review Your Details

Name:
City:
ZIP Code:
Telephone:
DOB:

Service Address:
State:
Email:
SSN:
Plan:

I authorize ETC or its duly appointed representative to: (1) access any records required to verify my statements herein; (2) to confirm my continued eligibility for Lifeline Benefit assistance; (3) to update my address to proper mailing address format; (4) to provide my name, telephone number, and address to the universal service Administrative company (USAC) (the administrator of the program) and/or its agents for the purpose of verifying that I do not receive more than one Lifeline Benefit; and (5) authorize social service agency representatives to discuss with and/or provide information to ETC verifying my participation in benefit programs that qualify me for Lifeline Benefit assistance, and (6) authorize ETC to share my information with my social service agency representatives for the purposes of improved communications including adding me to messaging systems, reporting service status and usage.

ETC is a Lifeline Benefit supported service. Lifeline Benefit is federal benefit, and only eligible subscribers may enroll. Customers who willfully make false statements in order to obtain the benefit can be punished by fine for imprisonment or can be barred from the program. Lifeline Benefit is available for only one line per household. A household is defined as any individual or group of individual who live together at the same address and share income and expenses. A Household is not permitted to receive Lifeline Benefit from multiple providers. Violation of the one-per-household rule constitutes a violation of FCC rules, and will result in the customer's de-enrollment from Lifeline Benefit. Lifeline Benefit is a non-transferable benefit, and a customer may not transfer his or her benefit to another person.

I further consent to receive calls and/or text messages that may deliver autodialed or pre-recorded messages from my social service agency, True Wireless or its duly appointed agent either using my telephone number assigned by True Wireless or provided by me herein or at a later date. I understand this is not a condition of purchase. 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 acknowledge that providing fraudulent documentation/information in order to receive assistance is punishable by law.

Account Created Date

Account Activation Date

MDN Activation Date

Program Name

Telgoo5 Plan Name

Carrier Status

Account Status

Carrier

Carrier Plan Code

Account Type

ESN

IMEI

NLADSubscriberID

Phone Model

Device Type

DeviceModelNumber

DeviceReimbursementDate

DeviceRetailCost

DeviceCoPayCost

DeviceReimbursementRate

DeviceDeliveryMethod

ConsumerFee

By clicking the confirm Signature button, you are electronically signing this form.

Signature (Electronically Signed By)

Today Date

Qualifying Beneficiary Details

Q1

Do you live with another adult?

Q2

Is the other household adult enrolled in the Lifeline Benefit?

Q3

Do you share money (income or expenses) with another household adult?

Qualify for Lifeline Benefit

PENALTY OF PERJURY

Terms and Conditions

Review Your Details