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Safety Net Lifeline Enrollment Consent Form

Lifeline Enrollment Form

Safety Net Wireless

Lifeline Consent Form

Completion of this form is required. This form is used for verifying your eligibility and enrolling you in Lifeline benefits with Safety Net Wireless. The information you provide will only be used for verification and enrollment purposes.

Consent Confirmation

I confirm that I have read and agree to the terms below.

First

Last

Date of Birth (MM/DD/YYYY)

Last 4 digits of SSN

Phone Number

Apartment Number

Street Address

City

State

ZIP Code

Eligibility

Criteria for Lifeline

Do you or anyone in your household participate in any qualifying government assistance programs?

Medical ID

If other, please specify

Current Lifeline Service Provider (if any)

I confirm that no one else in my household is currently receiving a Lifeline benefit.

Yes

Do you qualify based on income instead of a government program?

Yes, household income is at or below 135% of Federal Poverty Guidelines

No, I qualify through a government assistance program

Initials (Service Agreement Acknowledgement)

Initials (Transfer Consent if applicable)

Date / Time

Consent and Certification

I certify that all information provided is true and correct.
authorize verification of my eligibility.
I understand providing false information may result in termination of service.
I consent to electronic signature and digital processing of my application.
I authorize SafetyNet Wireless to complete, sign, and submit my California Lifeline application on my behalf.
I consent to transfer my Lifeline benefit to SafetyNet Wireless if I currently have it with another provider.
I certify that I meet the eligibility requirements and will notify SafetyNet Wireless within 30 days of any changes.

I consent to have this website store my submitted information so they can Proceed with my LifeLine enrollment.

I have read and agree to the and Consent and Certification Policy.

Complete Consent

Thankyou!