State of MI SL Application 2018.pdf

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SafeLink® is a LifeLine supported service. Lifeline is a federal bene�t that makes monthly telephone and broadband service more a�ordable for eligible households. Your household may receive the Lifeline bene�t for telephone service OR broadband service, but not both. For Lifeline telephone service, your household may receive the Lifeline bene�t for one mobile OR one �xed home telephone service, but not both. For Lifeline broadband service, your household may receive the Lifeline bene�t for one mobile broadband OR one �xed broadband service, but not both. Your household may not receive the Lifeline bene�t from more than one service provider. For the purpose of Lifeline, a household is an individual or any group of individuals who live together at the same address and share income or expenses. Lifeline is a non-transferable bene�t. You may not transfer your Lifeline bene�t to another person, even if he or she is eligible. You will lose your Lifeline bene�t and may be prosecuted by the United States government if you violate the one-per-household rule or otherwise make false statements to receive the Lifeline bene�t. SafeLink® is provided by TracFone Wireless Inc.

Check this box if you would like to receive pre-recorded special o�ers and promotional o�ers from TracFone at the Contact Telephone number provided above.

I hereby certify that I participate in the following public assistance program:

Conf irm applicant’s name & home address, provide mailing address if di�erent and complete mandatory personal information below.

Qualifying Home Address (No P.O. Box) Mailing Address if di�erent from your Qualifying Home Address (P.O. Box Allowed)

Address/Apt. No.

City

State ZIP Code

For questions please call: 1-877-631-2550

Mail application to: SafeLink Wireless®, PO Box 220009, Milwaukie, OR 97269-0009

Fax application to: 1-866-902-5756 To get your phone faster apply at www.safelink.com

COMPLETE FRONT & BACK

PART 2 PART

*Social Security # (Last Four Digits)

*Social Security # (Last Four Digits)

*Child or Dependent First Name

*Child or Dependent Last Name

MI

Only complete this part if applying via program and your child or dependent is the participant of the qualifying program.

Fields marked with (*) are mandatory. Please make sure to complete Section 1 (Part 1) and Section 3 with the parent or guardian information.

A household is eligible for Lifeline, if any member is a “quali�ed participant” of any program below.

Applicant Personal Information

*Legal First Name

*Legal Last Name

MI

*Birth Date (Month/Day/Year)

*Birth Date (Month/Day/Year)

Contact Phone Number

*To Keep Your Own Smartphone, you must have a compatible GSM phone (which includes T-Mobile and AT&T compatible phones).Your phone must also be unlocked.

Several other carriers also use GSM networks. To con�rm yours is included, call your carrier.

**Unused data will not carryover from month-to-month. A month equals 30 days.

OR

Receive 350 minutes and 1GB of FREE data every month.**

Receive 350 minutes and 1.5GB of FREE data for the �rst 3 months, 1GB thereafter.**

Keep-Your-Own-Smartphone* Safelink Smartphone Select Only One Plan/Phone Option

Address/Apt. No.

City

State ZIP Code

Medicaid (Please provide your 9 Digit Social Security number)

(By providing your Social Security number we can attempt to validate your Medicaid eligibility electronically)

FULL CERTIFICATION APPLICATION FOR MICHIGAN LIFELINE ASSISTANCE PROGRAM

The Michigan Department of Health and Human Services will confirm your eligibility.

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M I M A 0 3 1 8

Si gn at ur e

For questions please call: 1-877-631-2550

By signing below, I certify under penalty of perjury to each of the following:

Applicant Signature Date (Month/Day/Year)

YOU MUST INITIAL ALL STATEMENTS, THEN SIGN AND DATE APPLICATION. (YOUR APPLICATION CANNOT BE APPROVED WITHOUT THESE ITEMS)

1. I (or my dependent or other member of my household) currently receive(s) bene�ts from the federal program(s) identi�ed or my annual household income is at or below 135 percent of the Federal Poverty Guidelines.

David Sample DS

2. I understand that I must notify my service provider within 30 days (1) of my new address if I move or (2) if for any reason I no longer satisfy the criteria for receiving Lifeline bene�ts including: (a) I, or the eligible person in my household, no longer meet the program or income eligibility criteria or (b) my household receives more than one Lifeline discounted service (i.e., more than one Lifeline broadband service, more than one Lifeline telephone service, or both Lifeline telephone and Lifeline broadband services).

3. I acknowledge that my household can only receive one Lifeline Program bene�t and, to the best of my knowledge, my household is not receiving more than one Lifeline Program bene�t (i.e., only receiving a bene�t for one home phone service or for one mobile phone service, but not both).

4. I agree that SafeLink may transmit to the Administrator of the National Lifeline Accountability Database my full name, my full residential address, my date of birth, the last four digits of my Social Security Number, the last four digits of my Tribal Identi�cation Number, the telephone number that is associated with the Lifeline Program bene�t, the date on which the Lifeline Program service began, the date on which the Lifeline Program bene�t ended, the amount of support sought by my service provider, and the means through which I qualify for the Lifeline Program bene�t. I understand that transmission of this information is required to ensure the proper administration of the Lifeline Program. I also understand that if I refuse to have this information transmitted to the Administrator, I will be denied Lifeline Program bene�ts.

7. I may be required to recertify my continued eligibility at any time and failure to recertify my eligibility for the Lifeline Program will result in my removal from the Lifeline Program and termination of my Lifeline bene�t.

6. I acknowledge that willingly making false statements or providing false or fraudulent information to obtain Lifeline Program bene�ts is punishable by law and can result in �nes, imprisonment, de-enrollment, or being barred from the program.

5. All of my responses and acknowledgements provided on this recerti�cation form are true and correct to the best of my knowledge.

Initials Required sample:I hereby certify under penalty that:Initials Required

Initial

Initial

Initial

Initial

Initial

Initial

Initial

Your Safelink application cannot be approved without these items.

Have you provided your date of birth and the last four digits of your SSN?

To get your phone faster apply at www.safelink.com

Have you read and initialed all statements above and signed the application?

Mail application to: SafeLink Wireless®, PO Box 220009, Milwaukie, OR 97269-0009

Promo Code:

Fax application to: 1-866-902-5756 To get your phone faster apply at www.safelink.com

Visite www.SafeLink.com para llenar la inscripción en línea Llame a SafeLink al 1-877-631-2550 para completar una solicitud por teléfono

I authorize SafeLink Wireless® or its duly appointed representative to: (1) access any records required to verify my statements herein; (2) to confirm my continued eligibility for Lifeline assistance; (3) to update my address to a proper mailing address format; (4) to provide my name, telephone number, and address to the Universal Service Administrative Company (USAC) (the administrator of the program) and/or its agents for the purpose of verifying that I do not receive more than one Lifeline benefit; and (5) 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 Lifeline assistance; and (6) provide enrollment information, including my new phone number, to the Michigan Department of Health and Human Services and anyone acting on the Michigan Department of Health and Human Services’ behalf and consent to calls or text messages generated by automated technology being sent to that number that provide information regarding your health plan or health-related issues (including nutritional, medical and healthcare information and reminders). Consent to these messages is not a requirement to enroll in the SafeLink program. If you do not want to consent to such calls, you may enroll by calling our customer service department at 1-800-Safelink (723-3546). SafeLink service is offered pursuant to SafeLink Terms and Conditions, which can be found at www.SafeLink.com.

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