NEW YORK CERTIFICATION FORM
LIFELINE ASSISTANCE PROGRAM
Enrollment ID: 17101541
Section 1 Date: 03/24/2014
Please make sure that you provide correct personal information. Your information will be validated against Public Records
and any discrepancies could result in delays in your approval or rejection of service.
1. PLEASE PRINT name and physical residence address of person verifying for assistance:
florack ernest j 1395 03/22/1968
Legal Last Name Legal First Name Middle Initial Last 4 digits of SSN Birthday
1932 BAILEY AVE BUFFALO 14211
Street Address / Apt. Number (no PO BOX allowed) City Zip Code
Check here if your
NY ✔ address is temporary
Address Line 2 State Contact Email Address
Phone Number
Mailing Address
Mailing Address (PO BOX allowed) Mailing Address 2 City Zip Code State
Choose your plan (check one): 68 Free 125 Free ✔ 250 Free
Nationwide Text Nationwide
Monthly Text
Minutes Nationwide Text
(Up to 1250 texts) (Up to 1250 texts) (Up to 1250 texts)
All programs feature Local Calls, National Long Distance, Voicemail, Nationwide Text, Roaming at no Additional Cost, Free 911,
411 Directory Assistance at no Additional Cost. The 68 minutes plan includes 100+ International Long Distance Destinations. The
68 and 125 minutes plans feature carry-over minutes from month to month. You can send or receive up to 1250 texts per month
with any plan. The 250 minutes plan will not carry-over the minutes on your next monthly minutes delivery. However, if you redeem
additional minutes cards, all unused minutes will carry-over for three consecutive months.
Section 2
Household Income: Eligibility may apply if your total household income is at or below 135% of the Federal Poverty Guidelines
Persons in Family or Household Annual Income Monthly Income Please Select
1 $15.755 $1.313
2 $21.236 $1.770
3 $26.717 $2.226
4 $32.198 $2.683
5 $37.679 $3.140
6 $43.160 $3.597
7 $48.641 $4.053
8 $54.122 $4.510
For each additional person, add $5.481 $457
You must submit proof of total household income for income-based qualification.
(E.g. last year’s income tax form, Social Security, retirement/pension, Unemployment/Workmen’s Compensation statement of
benefits,divorce decree, child support award, or other official document containing income information, 3 months consecutive pay
stubs, letter from employer, etc) Please provide copies ONLY.
SafeLink is a Lifeline supported service. Lifeline is a federal benefit, and only eligible subscribers may enroll. Customers who willfully make falsestatements in
order to obtain the benefit can be punished by fine or imprisonment or can be barred from the program. Lifeline is available for onlone line per household. A
household is defined as any individual or group of individuals who live together at the same address and share income andexpenses. A household is not
permitted to receive Lifeline benefits from multiple providers. iolation of the one-per-household rule constitutes a violation of FCC rules, and will result in the
Customer’s deenrollment from Lifeline. Lifeline is a non-transferable benefit, and a Customer may not transfer his orher benefit to another person
Promo Code:
Section 3
You MUST place a check mark ( ) next to each statement, then Sign and Date below (your application cannot be approved without
these items).
I certify under penalty of perjury to each of the following:
✔ 1. I have income at or below the level specified above.
✔ 2. I understand that I must notify SafeLink within 30 days if I no longer meet the income eligibility threshold, if I or another member of my
household obtains Lifeline supported service from another carrier, or, for any other reason, I no longer qualify for Lifeline support.
✔ 3. I understand I may be required to recertify my continued eligibility for Lifeline at any time, and failure to do so will result in termination
of my Lifeline benefits.
✔ 4. If I change my address, I will provide my new address to SafeLink within 30 days.
✔ 5. My household will receive only one Lifeline benefit and to the best of my knowledge, my household is no already receiving a Lifeline
service.
✔ 6. The information contained in this application is true and accurate to the best of my knowledge, and I acknowledge that providing false
or fraudulent information to obtain Lifeline benefits is punishable by law.
✔ 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 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.
By signing below, I separately affirm and agree to each of the above statements
03/24/2014 14:35
Printed Name Date
Applicant Signature Promo Code
Electronically Signed by ernest j florack March 24, 2014
E-Signature
Referred by a Friend
Referred By A Friend
Antwon Cunningham 7162381887
Customer’s First Name Customer’s Last Name SafeLink Phone Number
Please check this box if you would like to receive pre-recorded special offers for SafeLink customers and promotional offers
from TracFone at the home telephone number provided in the contact information.
Please Return to
Mail Application: SafeLink Wireless
PO Box 220009
Milwaukie, OR 97269-0009
Or Fax Application: 1 (866) 902-5756
For questions concerning Lifeline, please call SafeLink
Wireless business office a 1 (800) SafeLink (723-3546)
