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The form requests details such as legal name, address, phone, and email, plus household income and person counts tied to Federal Poverty Guidelines. It includes plan options with monthly minutes and restrictions, requires documentation copies, and adds applicant attestations covering one-per-household eligibility, recertification, and authorization for record access and verification.",{"@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/pennsylvania-certification-form-lifeline-assistance-program-enrollment/306513/",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/pennsylvania-certification-form-lifeline-assistance-program-enrollment/306513.png","ImageObject",442,249,{"name":88,"@type":89},"Mary Man","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",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What personal information does the form require in Section 1?","Question",{"text":109,"@type":110},"Section 1 requires the verifier’s printed name and physical residence address, plus legal name fields, SSN last 4, birth date, mailing address, contact phone number, and email address.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does Section 2 determine eligibility?",{"text":114,"@type":110},"Section 2 uses household income by listing annual and monthly income amounts for family or household size, tied to 135% of the Federal Poverty Guidelines, and requires proof of total household income.",{"name":116,"@type":107,"acceptedAnswer":117},"What certifications and authorizations are required after Section 3?",{"text":118,"@type":110},"Section 3 requires a check mark next to each statement and a signature and date. The applicant certifies income eligibility, reporting obligations within 30 days, possible recertification, and authorization for SafeLink and related entities to access records and verify one-per-household Lifeline 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},306513,1791328714,{"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":76,"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},7421720224475,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","| | PENNSYLVANIA CERTIFICATION FORM LIFELINE ASSISTANCE PROGRAM\u003Cbr>Enrollment ID:   PromoCode:   |\n| --- | --- |\n| \u003Cbr>Section 1 Date: \u003Cbr>Please make sure that you provide correct personal information. Your information will be validated against Public Records and any discrepancies could result in delays in your approval or rejection of service.\u003Cbr>\u003Cbr>1. PLEASE PRINT name and physical residence address of person verifying for assistance:\u003Cbr>\u003Cbr>Legal Last Name Legal First Name MI SSN (Last 4) Birth Date\u003Cbr>(MM/DD/YYYY)\u003Cbr>\u003Cbr>Address Line 2 State Check here if your address is temporary Contact Phone Number Email Address\u003Cbr>Mailing Address\u003Cbr>\u003Cbr>\u003Cbr>Mailing Address (PO Box allowed) Mailing Address 2 City Zip Code State\u003Cbr>Choose your plan (check one)\u003Cbr>\u003Cbr> 68 Free\u003Cbr>Monthly Minutes\u003Cbr>(unlimited text messages)\u003Cbr>\u003Cbr> 125 Free\u003Cbr>Monthly Minutes\u003Cbr>(unlimited text messages)\u003Cbr>\u003Cbr> 350 Free\u003Cbr>Monthly Minutes\u003Cbr>(unlimited text messages)\u003Cbr>All programs feature Local Calls, National Long Distance, Voicemail, Nationwide Text, Roaming at no Additional Cost, Free 911, 411 Directory Assistance at no Additional Cost. The 68 minutes plan includes 100+ International Long Distance Destinations. The 68 and 125 minutes plans feature carry-over minutes from month to month. You can send or receive unlimited text messages per month with any plan. The 350 minutes plan will not carry-over the minutes on your next monthly minutes delivery. However, if you redeem additional minutes cards, all unused minutes will carry-over for three consecutive months. To purchase upgraded handsets go to [TracFone.com](TracFone.com) and select any phone except Android handsets.\u003Cbr>\u003Cbr>Section 2\u003Cbr>Household Income: Eligibility may apply if your total household income is at or below 135 % of the Federal Poverty Guidelines\u003Cbr>\u003Cbr>Persons in Family or Household Annual Income Monthly Income Please Select\u003Cbr>1 $15,890 $1,324\u003Cbr>2 $21,506 $1,792\u003Cbr>3 $27,122 $2,260\u003Cbr>4 $32,738 $2,728\u003Cbr>5 $38,354 $3,196\u003Cbr>6 $43,970 $3,664\u003Cbr>7 $49,586 $4,132\u003Cbr>8 $55,202 $4,600 For each additional person, add $5,616 $468\u003Cbr>You must submit proof of total household income for income based qualification (E.g. last year’s income tax form, Social Security, retirement/pension, Unemployment/Workmen’s Compensation statement of benefits, divorce decree, child support award, or other official document containing income information, 3 months consecutive pay stubs, letter from employer, etc) . Please provide copies\u003Cbr>ONLY.\u003Cbr>SafeLink is a Lifeline supported service. Lifeline is a 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 or imprisonment or can be barred from the program. Lifeline is available for only one line per household. A household is defined as any individual or group of individuals who live together at the same address and share income and expenses. A household is not permitted to receive Lifeline benefits 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. Lifeline is a non transferable benefit, and a Customer may not transfer his or her benefit to another person. |  |\n\n\n|  |  |\n| --- | --- |\n| \u003Cbr>Section 3 |  |\n| You MUST place a check mark (√) next to each statement, then Sign and Date below (your application cannot be approved without these items) .\u003Cbr>I certify under penalty of perjury to each of the following:\u003Cbr>1. I have income at or below the level specified above.\u003Cbr>2. I understand that I must notify SafeLink within 30 days if I no longer meet the income eligibility threshold, if I or another member of my household obtains Lifeline supported service from another carrier, or, for any other reason, I no longer qualify for Lifeline support.\u003Cbr>3. I understand I may be required to recertify my continued eligibility for Lifeline at any time, an","cbCaimD7dAoSoy4z","https://ap.wps.com/l/cbCaimD7dAoSoy4z","pdf",142628,"English","# Section 1\n## Personal information and contact details\n# Section 2\n## Household income eligibility table and proof requirements\n# Section 3\n## Certifications, signature, and authorization","[{\"question\":\"What personal information does the form require in Section 1?\",\"answer\":\"Section 1 requires the verifier’s printed name and physical residence address, plus legal name fields, SSN last 4, birth date, mailing address, contact phone number, and email address.\"},{\"question\":\"How does Section 2 determine eligibility?\",\"answer\":\"Section 2 uses household income by listing annual and monthly income amounts for family or household size, tied to 135% of the Federal Poverty Guidelines, and requires proof of total household income.\"},{\"question\":\"What certifications and authorizations are required after Section 3?\",\"answer\":\"Section 3 requires a check mark next to each statement and a signature and date. The applicant certifies income eligibility, reporting obligations within 30 days, possible recertification, and authorization for SafeLink and related entities to access records and verify one-per-household Lifeline participation.\"}]","PENNSYLVANIA CERTIFICATION FORM - LIFELINE ASSISTANCE PROGRAM - Enrollment | PDF",1789837295]