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    Enrollment Number: 1297496

    Uploaded by

    maddoggg

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    Download as PDF, TXT or read online from Scribd

    Enrollment Number: 1297496

    Uploaded by

    maddoggg
    118 views2 pages

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    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    118 views2 pages

    Enrollment Number: 1297496

    Uploaded by

    maddoggg

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 2

    ® Enrollment Number: 1297496

    REQUIRED GEORGIA APPLICATION FORM


    LIFELINE ASSISTANCE PROGRAM
    Please Read All Instructions Before Completing Date: 05/05/2009

    SECTION I
    1. PLEASE PRINT name and physical residence address of person applying for assistance:

    elliott richard 4782280607


    Last Name First Name Telephone Number

    100 FLANDERS DR WARNER ROBINS GA 31093-1808


    Street / Apartment No. City State Zip Code
    252258309 12/22/1973
    Social Security Number Birth Date
    maddoxshannon54@yahoo.com
    E-mail

    SECTION II

    I hereby certify that I participate in a least ONE of the following public assistance programs:

    Medicaid
    Food Stamps
    Temporary Assistance for Needy Families
    Supplemental Security Income (SSI)
    Senior Citizen low-income discount plan offered by local gas or power company
    Low-Income Home Energy Assistance Program (LIHEAP)
    Federal Public Housing Assistance / Section 8

    Please make sure that you complete SECTION III on next page
    SECTION III
    PLEASE READ AND SIGN THE FOLLOWING:

    I certify under penalty of perjury that:

    • I am eligible for and currently receive benefits from the public assistance program(s) as
    identified herein.
    • I do not currently receive Lifeline support for a telephone line serving my residential address,
    listed in page one of the application, and no other resident at my residential address
    participates in the Lifeline program; otherwise I agree to cancel my current household
    Lifeline support provider in favor of SafeLink Wireless ®
    .• I am head of household and I am not claimed as a dependent on someone else's federal or
    state tax return.
    • I will notify SafeLink Wireless® when I no longer qualify for any of the public assistance
    programs identified herein by calling 800-977-3768.
    • I will notify SafeLink Wireless® of any change of address by calling 800-977-3768.
    • The information contained on this form is true and correct to the best of my information and
    belief.

    I authorize SafeLink Wireless® or its duly appointed representative to access any records required to verify
    my statements herein and to confirm my continued eligibility for Lifeline assistance. I also authorize social
    service agency representatives to discuss with and/or provide information to SafeLink Wireless® verifying
    my participation in benefit programs that qualify me for the Lifeline assistance. I understand that completion
    of this application does not constitute immediate approval for Lifeline.

    By signing below, I acknowledge that providing fraudulent documentation in order to receive assistance is
    punishable by law.

    Printed Name _____________________________________

    Applicant Signature _____________________________________ Date _________________

    Please return information to: SAFELINK WIRELESS®


    PO Box 220009
    Milwaukie OR 97269-0009
    OR Fax application to: 1-800-834-7713

    For questions concerning Lifeline, please call SafeLink Wireless® business office at 800-977-3768

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