LIFELINE ENROLLMENT FORM This signed Lifeline Enrollment Form (“Enrollment Form”) is required to enroll you in T-Mobile’s Lifeline program. The National Verifier, not T-Mobile, determines your eligibility to receive Lifeline.
LIFELINE ENROLLMENT FORM
This signed Lifeline Enrollment Form ("Enrollment Form") is required to enroll you in T-Mobile's Lifeline program. The National Verifier, not T-Mobile, determines your eligibility to receive Lifeline. Only persons who have been determined to be eligible by the National Verifier should complete this Enrollment Form. If you have not qualified for Lifeline through the National Verifier, please visit https://nationalverifier.servicenowservices.com/lifeline to apply or complete and submit your paper application. The information you enter on this Enrollment Form must be the same as what you provided to the National Verifier.
· PERSONAL INFORMATION · NATIONAL VERIFIER APPLICATION ID: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX FIRST NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX MI: XXXXXX LAST NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX DATE OF BIRTH: XXXXXXXXXXXXXXXXXXXXXXXLAST 4 DIGITS OF SOCIAL SECURITY NUMBER OR TRIBAL ID NUMBER: XXXXXXXXXXXXXXXXXXXXX CONTACT PHONE NUMBER: XXXXXXXXXXXXXXXXXXXXXXXXX T-MOBILE PHONE NUMBER (IF APPLICABLE): XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
· RESIDENTIAL ADDRESS · Must be a street address (not a P.O. Box) and your principle residence. STREET ADDRESS: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX APT: XXXXXXXXXXXXXXX CITY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX STATE: XXXXXXXXXXXXXXXXXXXXXXXX ZIP: XXXXXXXXXXXXXXXX
Check here if the billing address is the residential address. Billing address may contain a P.O. Box.
BILLING ADDRESS: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX APT: XXXXXXXXXXXXXXX CITY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX STATE: XXXXXXXXXXXXXXXXXXXXXXXX ZIP: XXXXXXXXXXXXXXXX
· QUALIFICATION THROUGH DEPENDENT · Complete if you are qualifying through a child or dependent in your household. FIRST NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX MI: XXXXXX LAST NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX DATE OF BIRTH: XXXXXXXXXXXXXXXXXXXXXXXLAST 4 DIGITS OF SOCIAL SECURITY NUMBER OR TRIBAL ID NUMBER: XXXXXXXXXXXXXXXXXXXX
· BENEFIT TRANSFER REQUEST · I currently receive Lifeline benefits from another carrier and I request that T-Mobile submit a Benefit Transfer on my
behalf. I understand that I will only receive Lifeline benefits from T-Mobile and will lose my benefits from my current service provider.
· CERTIFICATION · I authorize government agencies and their authorized representatives to discuss with, receive from and provide information to T-Mobile that is relevant to my eligibility to receive Lifeline benefits from T-Mobile. I acknowledge that T-Mobile will, and I give my consent for T-Mobile to, use my personal information, including my name, address, and telephone number among other items as required, to verify my eligibility to receive Lifeline benefits with the Universal Service Administrative Company.
By my signature below, I certify that the information provided above is true and correct, and agree to the above Certification.
APPLICANT SIGNATURE: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
DATE: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
· SUBMISSION INSTRUCTIONS · This form must be completed in its entirety and submitted as provided below.
MAIL T-MOBILE LIFELINE SUPPORT P.O. BOX 37380 ALBUQUERQUE, NEW MEXICO 87176
FAX 813-348-5724
E-MAIL USLIFELINE@T-MOBILE.COM
· NOTICES · T-Mobile's applicable Terms and Conditions of service apply to existing or newly activated service (a copy may be obtained by visiting www.t-mobile.com). T-Mobile offers Lifeline services only in areas where it has been designated as an Eligible Telecommunications Carrier. Pennsylvania consumers with unresolved disputes regarding Lifeline services may contact the Public Utility Commission's Bureau of Consumer Services at 1-800-692-7380 for assistance in resolving their issues. Link Up is available only to qualifying consumers who also reside on federally-recognized tribal lands in certain states and if T-Mobile assesses an activation fee on the consumer. For purposes of the Lifeline program, the term "Tribal Lands" includes 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, and Hawaiian Home Lands.
Adobe PDF Library 20.6.74