Universal Assistance Intake Form
Our Phones Are Very Affordable and Come With FREE SERVICE.
1. Select All Products You Want To Purchase:
*
SIM Kit - $10 (for your own phone)
Standard Smartphone - $30(sold-out)
Standard Plus Smartphone - $40(sold-out)
Premium Smartphone - $50
Premium Plus Smartphone - $60
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Replacement Phone - $85
Elite S25 Ultra Elite 256MB - $295
Elite S25 Ultra Elite 512MB - $395
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8" Tablet - $189
10" Tablet - $225
CableTV - $59.97(subscription)
Website - $297(subscription)
Home Wi-Fi - $69.97(subscription)
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
No elements found. Consider changing the search query.
List is empty.
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
No elements found. Consider changing the search query.
List is empty.
3a. First Name
3b. Last Name
4. Date of birth: (Tip: Tap on the year 1st)
*
5. Social Security Number
*
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?
*
I authorized agency and it's reps to work on my behalf to apply, enroll, modify application to receive services selected.
*
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#
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