Enrollment

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Enrollment Number: 4371366

REQUIRED MICHIGAN APPLICATION FORM LIFELINE ASSISTANCE PROGRAM SECTION I
Date: 09/02/2010

Please make sure that you provide correct personal information. Your information will be validated against Public Records and any discrepancies could result in delays in your application approval.
1. PLEASE PRINT name and physical residence address of person applying for assistance: randall Last Name 2694199579 Cell-Phone Number 1114 10TH AVE S Street / Apartment No. jacqui First Name 9065537095 Contact Phone Number 9062410212 l Middle Home Phone Number Initial

randall_jacqui@yahoo.com E-mail ESCANABA City 2453 Last 4 digits of SSN MI State 49829-3108 Zip Code 05/17/1970 Birth Date 250 FREE monthly minutes
Talk Minutes

Choose your plan (check one) Program features (information only) Carry-Over minutes from month to month 100+ International long distance destinations Text Messaging Voicemail/Caller ID/Call waiting

68 FREE monthly minutes
International Calling & Texting

125 FREE monthly minutes
Carry-Over Minutes

YES YES YES (0.3 minutes per text) YES

YES NO YES (1 minute per text) YES

NO* NO YES (1 minute per text) YES

*If you choose this program, all unused minutes (including purchased cards and free minutes) will be removed/wiped out and will not carry-over on your next monthly minutes delivery.

SECTION II
I hereby certify that I participate in at least ONE of the following public assistance programs (select just ONE program from the list): Medicaid Supplemental Nutrition Assistance Program (Food Stamps) Temporary Assistance to Needy Families (TANF) Supplemental Security Income (SSI) National School Lunch (free program only) Low Income Home Energy Assistance (LIHEAP) Federal Public Housing Assistance/Section 8

Please make sure that you complete SECTION III on next page

SECTION III
PLEASE READ AND SIGN THE FOLLOWING:

Penalty of Perjury Under title 18 U.S.C. § 1621, whoever willfully states as...