Lifeline Discount Form

DISCOUNT FORM

Lifeline is a federal program that provides free or low-cost phone or internet service to low-income households through a monthly service discount.

Lifeline Discount

First Name

Last Name

Account Number

Phone

Address

City

State

Zip

Is your mailing address the same as above?

Yes

Mailing Address

City

State

Zip

Applicant must provide proof of eligibility for one of the following programs:

Do you currently receive Fuel Assistance?

Do you currently receive AFDC Assistance?

Do you currently receive Food Stamps?

Are you eligible for Merrimac's Real Estate Exemption?

Are you or your spouse a Disabled Veteran?

Are you or your spouse Disabled?

Select all that apply.

File Upload

Maximum file size: 516MB

By signing, I confirm that this application has been prepared or examined by me. Under the pains and penalties or perjury, I declare that to the best of my knowledge and belief, it and all accompanying documents and statements are true, correct and complete.

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