SERVICE REQUEST FORM For California

ABOUT ME
The person below MUST be the same person applying for Assurance Wireless federal Lifeline benefits. If you already receive a Lifeline phone discount, please write your name exactly as it appears on that account.
First Name: Home Address: Is this a temporary address?

MI: Last Name: Apt: Zip Code: Apt: State:

(if applicable)

Street Address:
(PO Boxes cannot be accepted)

City: Mailing Address: (if different from above) Street Address: City: Please provide a contact phone number:
(PO Boxes allowed)

State:

Zip Code:
(if applicable)

Email Address:

Get a FREE phone from Assurance Wireless by sending back this Service Request Form by 10/31/13. The State of California will then send you an official Application Form for the federal Lifeline Assistance program. Once you are approved by the State of California for the Assurance Wireless federal Lifeline Assistance program, you will get 250 FREE voice minutes and 250 FREE texts each month. Your FREE phone comes with 250 FREE voice minutes and 250 FREE texts good for 30 days while you wait for federal Lifeline Assistance program approval. Should you need more, the regular rate is 10 per voice minute or text (sent or received).

HOW TO GET A FREE PHONE

As a California resident, you may qualify for a FREE Assurance Wireless phone if you participate in certain public assistance programs or based on your household income. OPTION 1. You may qualify for a FREE phone if you participate in one of the following programs:
Medicaid/Medi-Cal Low-Income Home Energy Assistance Program (LIHEAP) Supplemental Security Income (SSI) Federal Public Housing Assistance or Section 8 CalFresh, Food Stamps or Supplemental Nutrition Assistance Program (SNAP) Women, Infants and Children Program (WIC) Healthy Families Category A National School Lunch Program (NSLP) Temporary Assistance for Needy Families (TANF) 1.  California Work Opportunity and Responsibility to Kids (CalWORKS) 2.  Stanislaus County Work Opportunity and Responsibility to Kids (StanWORKS) 3. Welfare-to-Work (WTW) 4. Greater Avenues for Independence (GAIN) Tribal TANF Bureau of Indian Affairs General Assistance Head Start Income Eligible (Tribal Only) Food Distribution Program on Indian Reservations

OPTION 2. You may qualify for a FREE phone based on household income:
Your Household Yearly Income must fall within the range indicated next to your Household Size. A Household is defined as any individual or group of individuals who live together at the same address and share income and expenses. Household Size 1-2 people 3 people 4 people Annual Income Limits $0 - $25,100 $0 - $29,300 $0 - $35,400

OR

If there are more than 4 people in your household add $6,100 for each additional person.
Effective through 5/31/14.

Your Household Size (including yourself):

Mail in the enclosed pre-addressed and pre-stamped envelope to: Assurance Wireless, PO BOX 686, Parsippany, NJ 07054-9726 -OR- Fax materials to: 1-877-732-3018

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TURN OVER TO COMPLETE

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You MUST include Proof of Program Participation or Proof of Income with this Service Request Form. Do not send original documents.

PROOF OF PROGRAM PARTICIPATION IS:  A copy of your benefit ID card or other program participation document  A copy of an eligibility letter from an authorized agency  A copy of a benefits statement (current or prior year)

PROOF OF INCOME IS: A copy of three consecutive months of ONE of these statements (from previous 12 months) Pay stubs Income statement from employer
OR

HELPFUL HINT: Make two copies of your Proof of Program Participation or Proof of Income:  One for now, to receive your free phone  One to mail in with your official Application Form from the State of California to apply for the federal Lifeline Assistance program

Front page only of prior years state, federal or tribal tax return State forms: 540, 540A, 540 2EZ, or 540X  Federal forms: 1040, 1040A, 1040EZ, 1040NR, 1040NR-EZ, 1040SS, or 1040X
OR

A copy of ONE of these documents Social Security benefits statement Veterans Administration benefits statement Retirement/Pension benefits statement Unemployment/Workers Compensation benefits statement Federal letter of participation in General Assistance Divorce decree or child support document containing income

FOR YOUR SECURITY

Youll need an account PIN to activate your Assurance Wireless phone and access your account. Youll need a Secret Answer in case you ever forget your PIN. Please write them down for safekeeping. CHOOSE YOUR ACCOUNT PIN: It must be 6 numbers long  No more than 3 consecutive numbers in a row (123456 wont work) YOUR ACCOUNT PIN:  Do not repeat numbers next to each other (44 wont work) No symbols or letters (@#PRTE wont work)
AND

YOUR SECRET ANSWER:

What is your favorite city? Your Secret Answer:

WHATS NEXT? 1 You will receive a FREE Assurance Wireless phone in the mail with
250 FREE voice minutes and 250 FREE texts that are good for 30 days to get you started while you wait for your official application for the federal Lifeline Assistance program to be approved. HELPFUL HINT: Be sure to write down your account PIN so you can activate your phone.

2 You will receive an official Application Form for the federal Lifeline Assistance program from the State of California.
Please fill out and send it in with a copy of your Proof of Program Participation or Proof of Income.

3 Once approved, you will be notified by the State of California and Assurance Wireless.