Lifeline Customer Opt-In Form

Lifeline is a federal program dedicated to making phone and internet service more affordable for low-income households. This benefit provides eligible consumers with a monthly discount of up to $9.25 for qualifying plans.

Lifeline Customer Opt-In Form

Qualify - Apply now to confirm you qualify for the Lifeline Program. You may be eligible to get Lifeline based on your income or participation in a government assistance program. Apply Here.
Sign Up to Get Lifeline - Let Citizens know you want to apply your Lifeline benefit to your services at Citizens by completing our Opt-In Form. Once we sign you up, you will start getting your Lifeline Benefit as of the 1st day of the next month.

Date

Application ID Number

Customer Name

Date of Birth

Address

City

State

Zip Code

Telephone Number

Mobile Number

Email Address

Eligible Qualifying Person within household other than Account Holder and date of birth(DOB):

Name

Last 4 SSN

Date of Birth

Please read and initial each of the following to participate in the Lifeline Program:

My household meets the income-based or program-based criteria for receiving Lifeline-supported service

I will notify Citizens within 30 days if, for any reason, my household no longer satisfies the criteria for receiving Lifeline. If my household no longer meets the income-based or program-based criteria, the household is receiving more than one benefit, or another member of the household is receiving program-supported service.

If I move to a new address, I will provide that address to Citizens within 30 days.

My household will receive only one Lifeline-supported service and to the best of my knowledge, my household is not already receiving a program-supported service.

The information contained in my certification is true and correct to the best of my knowledge.

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

I acknowledge that I may be required to recertify my continued eligibility at any time. My failure to recertify as to my household's continued eligibility will result in de-enrollment and the termination of my Lifeline benefits.

I acknowledge that my participation in the Lifeline program does not relieve my obligations to adhere to Citizens' posted rates, terms, and conditions, or other rules and regulations or tariffs that govern the services I receive.

I certify that I reviewed the above disclosures and consent to Lifeline program enrollment.

I certify that: I have confirmed my eligibility for the Lifeline through the National Verifier using: (Select One)

Are you transferring your Lifeline benefit from another company to Citizens?

Yes No

Please read and initial each of the following to transfer to Citizens in the Lifeline Program:

I am transferring my Lifeline benefit to Citizens.

The effect of the transfer of my Lifeline benefit will be applied to the Citizens' service and will no longer be applied to service retained from the transfer-out provider.

I may be subject to the transfer-out provider's undiscounted rates because of the transfer if I elect to maintain service from the transfer-out provider.

I am limited to one Lifeline benefit transfer transaction per service month, with limited exceptions for situations where the subscriber seeks to reverse an unwanted transfer or is unable to receive service from a specific provider.

I acknowledge that I was provided and read the disclosures herein, and that I give my informed consent to transfer my benefit to the transfer-in provider on the date indicated next to my signature.

Submit