IF YOU HAVE QUESTIONS ABOUTTHIS FORM, PLEASE CALL1-888-898-488824 HOURS PER DAYPLEASE RETURN THIS FORMTO THE ADDRESS SHOWN IN #4 BELOWPlease certify your eligibility:1. You may use either Section B orSection C to qualify2. Sign and date the form in Section D3. Attach documents to support your eligibility in Section B & C4. Mail the application to:Assurance Wireless, PO Box 7600, Mattoon, IL 61938Or Fax materials to: 1-877-732-3018A. PERSONAL INFORMATIONThe person below MUST BEthe same person applying for the discount. Please do not forget to sign the application below in Section D.B. PROGRAM-BASED ELIGIBILITYFill 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 ProgramSupplemental Security Income (SSI) (Not the same as Social Security Benefits)The National School Lunch Program’s Free Lunch Program (NSL)
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Household income in the United States, Wireless Service, Assurance Wireless service