[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-275690-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-275690-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","lifeline-program-application-form","Lifeline Program - Application Form","","Lifeline Program Application Form for collecting applicant and household eligibility details, including full legal name, contact information, date of birth, Social Security or Tribal Identification number, address, and whether the applicant resides temporarily or on Tribal Lands. The form requires selecting income and/or program-based qualification, listing household members receiving income, and reporting totals such as child support or VA benefits. It also specifies acceptable current income documentation types, excludes bank statements, and includes compliance language referencing Florida Statutes for false statements.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/lifeline-program-application-form/275690/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/lifeline-program-application-form/275690.png","ImageObject",442,249,{"name":42,"@type":43},"Ophelia","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-15",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What documents are required to support a Lifeline application?","Question",{"text":63,"@type":64},"The application cannot be approved until at least one current official income-related document is received and reviewed. Examples include Social Security award letters or 1099A, retirement/pension proof, U.S. 1040 (first two pages), W-2, VA award letter, unemployment award letter, workmen’s compensation award letter, and pay statements for three consecutive months.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How is household income counted on the form?",{"text":68,"@type":64},"The form counts “gross” income, not “adjusted gross” income. Social Security and pension are considered income and must be included in your total income on your 1040 tax form.",{"name":70,"@type":61,"acceptedAnswer":71},"Are bank statements acceptable as proof of income?",{"text":72,"@type":64},"No. Bank statements are not acceptable as proof of income for this application.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},275690,1791379779,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":136,"language":137,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":12,"update_tm":141,"read_time":30},7971461741311,"https://ap-avatar.wpscdn.com/avatar/74000253aff267980c6?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779345379180704826","Please provide the following information and return with your completed application and all supporting documentation.  \nYour application cannot be approved until at least one of the following official documents is received in our office and reviewed. All household income must be documented for each occupant who receives income. We accept any of the following official documents; however, please send us only the income documents for each occupant that apply to your household and it must be CURRENT:  \n􀁸 Social Security award letter or 1099A that states amount received  \n􀁸 Proof of retirement, pension and/or annuity amounts  \n􀁸 U.S. 1040 income tax form (first two pages only)  \n􀁸 Most recent W-2 wage and tax statement  \n􀁸 VA award letter that shows amount received  \n􀁸 Unemployment award letter or statement of amount received with recipients full name  \n􀁸 Workmen’s Compensation award letter that states amount received  \n􀁸 Divorce or Child Support decree stating award amount  \n􀁸 THREE months of consecutive pay statements showing “gross” pay from current employment  \n􀁸 If there is $0 income in the household, we require a written statement signed and dated by you verifying that you have no household income.  \n􀁸 Bank statements are NOT acceptable as proof of income  \nWe count “gross” income NOT “adjusted gross” income. Social Security and pension are considered income and must be added to your “total income” on your 1040 tax form. Please send us COPIES ONLY! Documents will not be returned to you. Please forward the requested documents to the address listed above in the letterhead or fax it to 1-850-487-6419.  \nHow many people live in your household?  \nNumber of people receiving income?  \nTotal child support/alimony received?  \nTotal VA benefits received?  \nTotal household income (monthly or yearly)? Monthly   Yearly   Who is your telephone provider?    \nBy signing this application, applicant is aware that pursuant to Section 837.06, Florida Statutes, whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree.  \n\n|  |\n| --- |\n|  |\n|  |\n\nLifeline Program  \nApplication Form  \n2.  \nYour Information  \nAll fields are required unless indicated. Use only CAPITALIZED LETTERS and black ink to fill out this form.  \nWhat is your full legal name?  \nThe name you use on official documents, like your Social Security Card or State ID. Not a nickname.  \nFirst  \nMiddle (optional) Suffix (optional)  \nLast  \nWhat is your phone number (if you have one)? What is your date of birth?  \nMonth Day Year  \nWhat is your email address (if you have one)?  \nWhat are the last 4 numbers of your Social Security Number (SSN)?  \nIf you do not have a SSN, what is your Tribal Identification Number?  \nWhat is the best way to reach you?  \nemail phone text message mail  \nPage 2 of 8 [Universal Service Administrative Company | www.lifelinesupport.org](Universal Service Administrative Company | www.lifelinesupport.org)  \nNeed help? Call the Lifeline Support Center at 1-800-234-9473  \nFCC FORM 5629  \nLifeline Program  \nApplication Form  \nOMB APPROVAL EDITION 3060-0819  \n2.  \nYour Information (continued)  \n*Tribal lands include any federally recognized Indian tribe’s reservation, pueblo, or colony, including former reservations in Oklahoma; Alaska Native regions established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688); Indian allotments; Hawaiian Home Lands—areas held in trust for Native Hawaiians by the state of Hawaii, pursuant to the Hawaiian Homes Commission Act, 1920 July 9, 1921, 42 Stat. 108, et. seq., as amended; and any land designated as such by the Commission for purposes of this subpart pursuant to the designation process in the FCC’s Lifeline rules.  \n\n| What is your home address? (The address where you will get service. Do not use a P.O. Box)\u003Cbr>Street Number and Name\u003Cbr>Apt., Unit, etc. City\u003Cbr>State Zip Code","cbCait5qbZ5e1QIg","https://ap.wps.com/l/cbCait5qbZ5e1QIg","pdf",2881313,9,"English","# Your Information\n## Income documentation and household income details\n## Contact details and identification\n## Address information\n# Qualify for Lifeline\n## Program-based eligibility\n## Income-based eligibility\n# Certification and compliance","[{\"question\":\"What documents are required to support a Lifeline application?\",\"answer\":\"The application cannot be approved until at least one current official income-related document is received and reviewed. Examples include Social Security award letters or 1099A, retirement/pension proof, U.S. 1040 (first two pages), W-2, VA award letter, unemployment award letter, workmen’s compensation award letter, and pay statements for three consecutive months.\"},{\"question\":\"How is household income counted on the form?\",\"answer\":\"The form counts “gross” income, not “adjusted gross” income. Social Security and pension are considered income and must be included in your total income on your 1040 tax form.\"},{\"question\":\"Are bank statements acceptable as proof of income?\",\"answer\":\"No. Bank statements are not acceptable as proof of income for this application.\"}]","Lifeline Program - Application Form | PDF",1789488899]