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Unformatted text preview: IF YOU HAVE QUESTIONS ABOUT THIS FORM, PLEASE CALL 1-888-898-4888 24 HOURS PER DAY PLEASE RETURN THIS FORM TO THE ADDRESS SHOWN IN #4 BELOW Please certify your eligibility: 1. You may use either Section B or Section C to qualify 2. Sign and date the form in Section D 3. Attach documents to support your eligibility in Section B & C 4. Mail the application to: Assurance Wireless, PO Box 7600, Mattoon, IL 61938 Or Fax materials to: 1-877-732-3018 A. PERSONAL INFORMATION The person below MUST BE the same person applying for the discount. Please do not forget to sign the application below in Section D. B. PROGRAM-BASED ELIGIBILITY Fill in all bubbles for all program(s) the person in Section A is currently enrolled. You must prove your eligibility to subscribe to this program. You must attach a copy of your benefit ID card. As an alternative, you may send a copy of an eligibility letter from an authorized to confirm your eligibility. Medicaid Temporary Assistance to Needy Families (TANF) Food Stamps/SNAP United Tribes Food Distribution Program Supplemental Security Income (SSI) (Not the same as Social Security Benefits) The National School Lunch Programs Free Lunch Program (NSL) (Supporting Documentation WILL NOT Be Returned) OR C. INCOME-BASED ELIGIBILITY Calculate...
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This note was uploaded on 03/17/2012 for the course TECHNOLOGY 2012 taught by Professor Assurnace during the Spring '12 term at University of Phoenix.

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