Pre Registration

You are one step closer to getting connected to the resources you need.

Please complete the information below, and you will be contacted by a Navigator as soon as possible.We look forward to assisting you!

Pre-Registration Form

"*" indicates required fields

Date*

Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Which services are you initially interested in (select all that apply):

I’ve had the following before

Lifeline Benefits (Phones) ACP Benefits (Tablets)

Would you like to receive a FREE*

Check all that apply Health Box Tablet Phone

ADULT OR ADVOCATE APPLICANT INFORMATION

Legal name (as on Award Letter)*

First Last

Phone*Email*

Do we have permission to email, call or text?*

Yes No

Date of Birth*

Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Last 4 SSN:*

Benefits or Advocate Address:

Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code

Which of the following best describe you?*

White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Other

MINOR CHILD/CHILDREN

Legal name (as on Award Letter-Use more forms if needed)

First Last

Date of Birth

Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Last 4 SSN

ADULT OR MINOR IS CURRENTLY RECEIVING

Check all that appy*

EBT/SNAP SSI Medicare Medicaid WIC Housing Vet. Pen. Vet Survrs. Ben. School Lunch Private Insurance Income Below $29,160 Unemployment Pell Grant

School District School Name DOCS THAT MAY BE REQUESTEDIf documents are requested upload them here. Drop files here or Select files Max. file size: 5 MB.

Check all the documents that you are uploading.

State ID Award Letter SSN Card W2 Check Stubs

RESOURCES

How many adults are in the household?*How many children are in the household?*

Would you like more resources for your family?*

Yes No

Community Resources Needed:*

Food Shelter Basic Needs Senior Serv. Insurance Employment

Consent*

Yes, I agree to allow your organization to assist me in applying for the programs selected in my pre-application.

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