Universal Assistance Intake Form
BRING YOUR OWN DEVICE
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or
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Buy One Of Our Very Affordable Phones
All Come With FREE SERVICE.
1. Select All Products You Want To Purchase:
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SIM Kit - $30 (for your own phone)
Standard Smartphone - $89.99
Standard Plus Smartphone - $99.99
Premium Smartphone - $129.99(best value)
S25 Elite Ultra Smartphone - $295
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Replacement Phone - $100
Elite S25 Ultra Elite 256MB - $295
Elite S25 Ultra Elite 512MB - $395
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8" Tablet - $189
10" Tablet - $225
Website - $297(subscription)
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If You Do Not Have A Benefit Or ID
We Have Pre-Paid Plans w/
Unlimited Talk & Text
Pre-Pay Plans. (No Benefits Or ID Required)
SELECT AN UNLIMITED PRE-PAID PLAN HERE
Unlimited Talk & Text No Data $30/mo
Unlimited Talk & Text, 3 GB Data $35/mo
Unlimited Talk & Text, 5 GB Data $40/mo
Unlimited Talk & Text, 8 GB Data $45/mo
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1a. Select All Assistance Needed
Select All Services You Need
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Food Assistance
Phone Service
Home Healthcare
Housing Assistance
Internet Service
Utility Assistance
Medical/Health Assistance
Health & Fitness
Employment Assistance
Education Or Training
Clothing Assistance
Funeral Plans & Services
Drug or Alcohol Assistance
Domestic Issues
Legal Services
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2. Select All Qualifying Benefits You Have
Select all benefits you have
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None yet. I am applying for benefits soon
Medicaid
Foodstamps
SSI (Supplemental Income)
SSDI (disability) run under INCOME.
SSA or (Retirement) run under INCOME
Housing (HUD, Section8, Voucher)
Income: W2 or Tax Return
Veteran's Survivor Benefits
Medicare(Red, White & Blue Card) Not for Lifeline
Type an Option
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3a. First Name
3b. Last Name
4. Date of birth: (Tip: Tap on the year 1st)
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5. Social Security Number
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Address
Street Address
City
State
Postal code
Name of Apartment, Facility, or Shelter
7. Contact Number To Reach You:
8. Email:
9. Where did you hear about us?
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I authorized agency and it's reps to work on my behalf to apply, enroll, modify application to receive services selected.
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Clear
Document Page
If you have any of these documents available please enter them here, otherwise skip this section.
1. State ID or Driver's License
State ID or Driver's License
2. Award Letter (Foodstamps, Medicaid, SSI, Disability, Social Security(Retirement), Utility Bill
Award Letter or Utility Bill
3. Social Security Card
Social Security Card
Birth Certificate
Birth Certificate
W2
W2
DEVICE IMEI
To find it, dial: *#06#
Pic of IMEI
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