SafetyNet — Activation

1 · Applicant

First name

Last name

Date of birth Last 4 of SSN Mobile phone (optional — leave blank if none) Email (required) Best way to reach Service street address

Apt / Unit (optional)

City

State

ZIP

2 · Eligibility

How does the customer qualify?

Qualifying program

Customer lives on Tribal lands (FCC §54.400(e))

Qualifying through a child/dependent (Benefit Qualifying Person)

3 · Disclosures, Consents & Certifications

Lifeline Disclosures. Lifeline is a federal benefit (FCC) providing discounts on broadband and/or voice service. Providing false information to obtain the benefit can result in fines, imprisonment, de-enrollment, or being barred from the program.

One Benefit Per Household. Only one Lifeline benefit is allowed per household — individuals at the same address sharing income and expenses. Receiving benefits from multiple providers violates FCC rules and results in de-enrollment. The benefit is non-transferable to another household or person.

Eligibility & Verification. Eligibility is determined via the National Verifier / NLAD or FCC-approved alternatives administered by USAC (888-224-3213, usac.org/lifeline).

Terms. By submitting, the applicant agrees to SafetyNet's Terms, Acceptable Use and Privacy policies at safetynetwireless.com/terms/. Assigning a telephone number constitutes "activating the service" per 47 CFR §54.407(c)(1).

I consent to use of this electronic form; I may request a paper copy or enroll by phone (1-844-946-6768), and may withdraw consent before activation.

I authorize SafetyNet & partners to collect, use, share, and retain my personal information for Lifeline eligibility, enrollment, and compliance, including sharing with USAC. Denial of consent = denial of benefits.

I consent to be contacted by phone, text, email or mail for processing and marketing (auto/prerecorded incl.). Marketing consent is optional; reply STOP to opt out. Msg/data rates may apply.

Certifications — under penalty of perjury, I certify:
• I meet Lifeline's income- or program-based eligibility (47 CFR §54.409).
• I will notify SafetyNet within 30 days if I no longer qualify or my household gets more than one benefit.
• If Tribal, I live on Tribal lands (47 CFR §54.400(e)).
• If I move, I'll provide my new address within 30 days.
• My household will receive only one Lifeline service and isn't already receiving one.
• The information provided is true and correct; false statements are punishable by law.
• I may be required to re-certify and failure to do so results in de-enrollment (47 CFR §54.405(e)(4)).

The customer has read and certifies all of the above under penalty of perjury.

Applicant signature — type full legal name

4 · Verify & Submit

Checking…