NEW YORK APPLICATION

Questions? Please Call 1-888-898-4888

1 PERSONAL INFORMATION (Please do not forget to SIGN the application in Section 4.)

The information below MUST be that of the person applying for Assurance Wireless service. You MUST be at least 18 years of age to apply.

First Name: Last Name: Email:

(If applicable)

Date of Birth: Last 4 digits of Social Security Number:

mm dd yyyy

Home Address: Is this a temporary address? Home Telephone Number:

(If applicable)

Street Address: Apt:

(PO Boxes or General Delivery cannot be accepted)

City: State: Zip Code:

Mailing Address: (if different from above)
Street Address: Apt:
(PO Boxes allowed)

City: State:_ Zip Code:

2 ELIGIBILITY

To be eligible for Assurance Wireless service, you or a member of your Household must participate in a qualifying Program listed
in 2A, OR your Household Yearly Income must meet the qualifications for Lifeline Assistance listed in 2B.
If you are NOT the Program participant, please provide the first name and last name of the person participating in a qualifying Program listed in 2A.

Program participant:
(First Name) (Last Name)

2A PROGRAM-BASED ELIGIBILITY

Proof of Program participation is NOT required for these Programs - Put a check mark
your household is enrolled in:
✓ next to the qualifying Program(s)
Medicaid (Medicare is not acceptable) Temporary Assistance for Needy Families (TANF)
Supplemental Nutrition Assistance Program Low-Income Home Energy Assistance Program
(SNAP)/Food Stamps (LIHEAP)
Supplemental Security Income (SSI)
(Not the same as Social Security Benefits)

SEND Proof of Program participation for these Programs - Put a check mark ✓ next to the qualifying Program(s) your household is enrolled in:
Federal Public Housing Assistance The National School Lunch Program’s Veterans and Survivors
(Section 8) Free Lunch Program Pension Benefit
SEND a copy of ONE of these - Put a check mark
Program participation document
✓ next to the document that you are sending and please DO NOT send originals:
Notice Letter of participation Statement of benefits
(your benefit ID card) (official letter from an authorized agency) (from the past 12 months)

OR
INCOME-BASED ELIGIBILITY
2B
SEND Proof of Income if your household does not participate in a qualifying Program listed in 2A - Put a check mark
that you are sending and please DO NOT send originals:
✓
next to the document

To qualify, your Household Yearly income for your Household Size must be
Send a copy of ONE of these:
within the ranges listed below:
Prior year’s state or federal Income tax return
(A Household is one or more individuals who live together at the same address
Current Income statement from employer and share Income and expenses.)
Federal notice letter of participation in General Assistance How many individuals in your Household
Divorce decree or child support document containing Income household? (including yourself) Size Yearly Income
OR 1 1 $0 - $16,28 1
Send proof of 3 months in a row in the past 12 months: 2 2 $0 - $21,924
Social Security benefits statement 3 3 $0 - $27,567
Veterans Administration benefits statement 4 or more_____________ 4 $0 - $33,210*
(list how many)
Retirement or pension benefits statement
Current paycheck stub *To calculate the Yearly Income range for households with more than 4
Unemployment or Workers’ Compensation benefits statement members, add $5,643 for each additional person.

Send in your application with the proof of eligibility (from Section 2.)

Mail to: Fax to:

TURN OVER
Assurance Wireless, PO Box 686 1-877-732-3018 TO COMPLETE
NY999999999999XB Parsippany, NJ 07054-9726
 NY999999999999XB

3 FOR YOUR SECURITY

If you qualify, you’ll need an Account PIN to access your account and 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 • Do not repeat numbers next to each other (44 won’t work)
• No more than 3 consecutive numbers in a row (1234 won’t work) • No symbols or letters (@#PRTE won’t work)

YOUR ACCOUNT PIN: AND YOUR SECRET ANSWER:

What is your favorite city?
Your Secret Answer:

IMPORTANT INFORMATION ABOUT THE LIFELINE PROGRAM: Assurance Wireless is a Lifeline supported service. Lifeline is a federal benefit, and only eligible
subscribers may enroll. Customers who willfully make false statements in order to obtain the benefit can be punished by fine or imprisonment or can be de-enrolled
or barred from the program. One Lifeline discounted service (landline or wireless) is available per household. A household is one or more individuals who live
together at the same address and share income and expenses. A household is not permitted to receive Lifeline benefits from multiple providers. Violation of the one-
per-household rule constitutes a violation of federal rules and will result in de-enrollment from the Lifeline program and potential prosecution by the United States
government. Lifeline is a non-transferable benefit. Service cannot be transferred to any individual, including another eligible, low income consumer.

4 SIGNATURE

By signing and placing your initials next to all statements below, you are certifying under penalty of perjury that each of the below
statements are true.
• I authorize Assurance Wireless or its agent to access any records (including financial records) required to verify my statements herein and to confirm my
eligibility for Assurance Wireless service. I authorize state or federal agency representatives to discuss with, and/or provide information to, Assurance
Wireless verifying my participation in public assistance Programs that qualify me for Assurance Wireless service.
• I consent to have my personal identification information shared with the Universal Service Administrative Company (USAC) (the Lifeline program
administrator) and/or its agents for the purpose of confirming that neither I nor my household receives more than one Lifeline benefit.
• I authorize Assurance Wireless to provide access to or release any records required for the administration of Assurance Wireless service.
• I understand that the completion of this application does not constitute immediate approval for Assurance Wireless service.
• I acknowledge that once I have enrolled in a Lifeline-supported broadband plan with one carrier, I may need to wait 12 months before transferring my benefit
to a new carrier. If approved, I understand that Assurance Wireless will become my Lifeline broadband provider for 12 months from the date of enrollment.

YOUR APPLICATION CAN NOT BE APPROVED WITHOUT YOUR INITIALS ON ALL THE CERTIFICATIONS BELOW !
I certify that I, or a member of my household meets the income-based or program-based eligibility criteria for receiving Lifeline; AND
INITIALS

I certify that I will notify Assurance Wireless within 30 days if for any reason I no longer satisfy the criteria for receiving Lifeline including, as
INITIALS
relevant, if I no longer meet the income-based or program-based criteria for receiving Lifeline support, if I am receiving more than one Lifeline
benefit, or if another member of my household is receiving a Lifeline benefit; AND

I certify that if I move to a new address, I will provide that new address to Assurance Wireless within 30 days; AND
INITIALS

I certify that my household will receive only one Lifeline service and, to the best of my knowledge, my household is not already receiving a
INITIALS
Lifeline service; or if I currently have a Lifeline plan with a different phone service provider, and if I am approved for Assurance Wireless service,
I consent to the transfer of my Lifeline benefit to Assurance Wireless and understand that once the transfer is complete, I will lose my Lifeline
program benefit with my current phone service provider; AND

I certify that the information contained in my certification form is true and correct to the best of my knowledge; AND
INITIALS

I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law; AND
INITIALS

I acknowledge that I may be required to re-certify my continued eligibility for Lifeline at any time, and my failure to re-certify as to my continued
INITIALS
eligibility will result in de-enrollment and the termination of my Lifeline benefits.

! YOUR APPLICATION CANNOT BE APPROVED WITHOUT YOUR INITIALS ON ALL THE STATEMENTS ABOVE AND YOUR
SIGNATURE BELOW.

✓ Have you provided your Date of Birth

and your last 4 digits of SSN?
X ✓ (ifHave you attached proof of eligibility?
proof of eligibility documentation is requested)
SIGNATURE (Please use blue or black ink)
✓ Hstatements
ave you INITIALED all of the
in #4 above and SIGNED the
TODAY’S Application?
DATE
PRINTED NAME mm dd yyyy
Your Application cannot be approved
without these items.