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Name	First Last

Address

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City

Zip Code

Phone	### - ### - ####

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Date Of Birth	MM / DD / YYYY

Last 4 Digits Of SS#

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Lifeline benefits are limited to a single line of service per residence. You may not receive multiple Lifeline or Link Up discounts. You may apply your Lifeline discount to either one landline or one wireless number, but you cannot have the discount on both. Note that not all Lifeline services are currently marketed under the name Lifeline. Are you currently receiving a Lifeline supported service from any other provider?

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