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Assurance Cell Phone - Kansas IF YOU HAVE QUESTIONS ABOUT...

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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 Program’s Free Lunch Program (NSL)
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