Lifeline Program Annual Recertification Form
The Lifeline Program is a federal program that helps eligible consumers pay for wireless or home telephone service by discounting monthly
service bills. At least once each year, consumers who receive Lifeline Program-supported service must recertify that 1) they remain eligible
to receive Lifeline Program-supported service, and 2) no one else in their household receives Lifeline Program-supported service.
You must complete all sections of this form within 30 days to recertify your continued eligibility for the Lifeline Program or your service
provider will remove the Lifeline Program benefits from your account and you will be de-enrolled from the Lifeline Program.
Please have the following information available:
- Your home address.
- Your Social Security Number.
- The qualifying program for which you are eligible OR the total income for your household.
4 digits Required