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Applicants must certify participation in qualifying public assistance programs, acknowledge perjury penalties under U.S. law, and agree to authorization for verification, eligibility confirmation, and address updates. Includes privacy consent, signature and date, and submission instructions via mail or fax with a promo code.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/application-for-illinois-lifeline-assistance-program-application-form/306511/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/application-for-illinois-lifeline-assistance-program-application-form/306511.png","ImageObject",442,249,{"name":88,"@type":89},"Kurz","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-25","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information does the Illinois Lifeline application collect from the applicant?","Question",{"text":109,"@type":110},"It collects applicant name details and phone numbers, plus plan selection and identity verification fields such as the last four digits of SS# and birth date.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Which public assistance programs qualify for Lifeline under this form?",{"text":114,"@type":110},"The form lists Medicaid, Federal Nutrition Assistance Program (Food Stamps), TANF, SSI, National School Lunch (free program only), LIHEAP, and Federal Public Housing Assistance/Section 8.",{"name":116,"@type":107,"acceptedAnswer":117},"What does the applicant authorize SafeLink Wireless to do?",{"text":118,"@type":110},"The applicant authorizes access to records to verify statements, confirm continued eligibility, update the mailing address format, and allow representatives to discuss and provide information verifying participation.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},306511,1791626089,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},2336478945635,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Moisten and Seal  \nBUSINESS REPLY MAI儿L  \nFIRSTCLASS MAIL PERMIT NO609 PORTLAND OR  \nPOSTAGE WIL BE PAID BY ADDRESSEE  \nIlmlalHHIIalHulH\"lHallmlIlPI  \nSAFELINK WIRELESS@  \nP.O.BOX 220006  \nMILWAUKIE,OR 97269-6601  \nTHE  \nTHE  \n250FREE 250FREEmonthly minutesmonthly minutesANDFREEANDFREEMinutes for Local &FREELong Distance CallsTextingand More!FREEMinutes for Local&Long Distance CallsTextingand Mcre!cell phone program.*cell phone program.sunerior CoverajeSinerior coverageSafeLsnkSafeLsnkWIRELESSWIRELESS°Pay Nothing!Pay Nothing!  \n●NO Contracts·NO Credit Checks ·NO Fees·NO Contracts ·NO Credit Checks ·NO Fees*You may qualify if you participate in*You may qualify if you participate inprograms like Food Stamps and Medicaid.programs like Food Stamps and Medicaid.For additional programs and to get your phone FASTERFor additional programs and to get your phone FASTERgo to the website below and enter the promo codego to the website below and enter the promo codelocated at the bottom of application enclosed.located at the bottom of application enclosed.  \nSafeLsnk.com  \nSafeLsnk.com  \n111456-1L  \n# APPLICATION FOR ILLINOIS LIFELINE ASSISTANCE PROGRAM\n\nPlease readall instructions before completing.Information will be validated.Discrepancies could result in delays.  \nMI  \nLast Name  \nFirst Name  \nHome Phone Number  \nCell Phone Number  \nContact Phone Number  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nStreet/Apartment No.  \nCity  \nState  \nZip Code  \n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\n\n|  |  | Last Four Digits of SS\\#  \u003Cbr>Birth Date(Month/Day/Year)   |  |\n| --- | --- | --- | --- |\n| Plan Features  \u003Cbr>Choose your plan(check one)   | FREE  \u003Cbr>Monte   | 125  \u003Cbr>FREE  \u003Cbr>Monte   | 250  \u003Cbr>FREE  \u003Cbr>Monthe   |\n|  |  |  |  |\n| Local calls   |  |  |  |\n| National long distance   |  |  |  |\n| Voice mail   |  |  |  |\n| Nationwide text   |  |  |  |\n| Roaming at no additional cost   |  |  |  |\n| Free 911   |  |  |  |\n| 411 Directory Assistance*   |  |  |  |\n| Carry-over minutes from month to month   |  |  |  |\n| 100+International long distance destinations   |  |  |  |\n\nEmail Address  \n*Minutes can be used for 411 calling at no additional cost.  \n**Ifyou 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.  \nTo apply for SafeLink you must belong to ONE of the following Public Assistance Programs(No proof necessary).  \nIhereby certify that I participate in at least ONE of the following public assistance programs:  \nMedicaid(Not the same as Medicare)  \nFederal Nutrition Assistance Program(Food Stamps)  \nTemporary Assistance for Needy Families(TANF)  \nSupplemental Security Income SSI (Not the same as Social Security Benefits)  \nNational School Lunch (free program only)  \n□  Low Income Home Energy Assistance(LIHEAP)  \nFederal Public Housing Assistance/Section 8  \nPlease read and sign the following:  \nBY SIGNING BELOW.IACKNOWLEDGETHAT PROVIDING FRAUDULENT DOCUMENTATION/INFORMATIONINORDERTO RECEIVE ASSTANCE IS PUNISHABLEBY LAW.  \n# PENALTY OF PERJURY\n\nUnder title 18 U.5.C.51621,whoever willfully states as true any material matter whic he does not believe to be true in astatement under penalty of perjury,is guilty of perjury and shall,except as otherwise expresslyprovided by law,be fined or imprisoned not more than five years,or both.  \nIcertify under penalty of perjury that:  \n·Iqualify based on the program participation as identifed herein.  \n·Ido not currently receive Lifeline support fora land or wireless line serving my residential address.No other resident at my address partici","cbCaibQ7yB9YnfhK","https://ap.wps.com/l/cbCaibQ7yB9YnfhK","pdf",575603,"English","# Applicant Information\n## Contact Details\n# Plan Features Selection\n## Choose Your Plan\n# Public Assistance Eligibility\n## Qualifying Programs\n# Certifications and Penalties\n## Penalty of Perjury\n# Authorization and Privacy\n## Sign and Date","[{\"question\":\"What information does the Illinois Lifeline application collect from the applicant?\",\"answer\":\"It collects applicant name details and phone numbers, plus plan selection and identity verification fields such as the last four digits of SS# and birth date.\"},{\"question\":\"Which public assistance programs qualify for Lifeline under this form?\",\"answer\":\"The form lists Medicaid, Federal Nutrition Assistance Program (Food Stamps), TANF, SSI, National School Lunch (free program only), LIHEAP, and Federal Public Housing Assistance/Section 8.\"},{\"question\":\"What does the applicant authorize SafeLink Wireless to do?\",\"answer\":\"The applicant authorizes access to records to verify statements, confirm continued eligibility, update the mailing address format, and allow representatives to discuss and provide information verifying participation.\"}]","APPLICATION FOR ILLINOIS LIFELINE ASSISTANCE PROGRAM - Application Form | PDF",1789837292]