You can go directly to the Assurance Wireless page, or continue reading to learn about their application:
We’ve had quite a few people ask us what’s in the Assurance Wireless Application that one must fill out to order a government cell phone. It’s a simple form that may literally take you all of one minute to complete. Here are the various elements of the one page application from Assurance Wireless:
NOTE: You can choose to complete Section B or Section C. Only complete one.
Section A Personal Information
This consists of your name, home telephone number (will become your application ID), street address (PO Box not accepted), city, state and zip.
Section B: Program-Based Eligibility
If you are qualifying for your phone based upon your participation in a government assistance program, mark the the checkbox corresponding to the program in this section. There is no need to provide program documentation.
Section C: Income-based Eligibility
If you are qualifying based upon your low-income, you must complete this short section. Simply check your household size, and the total income of all adult persons residing in your home.
Note that you will have to attach proof of income. This can be your prior year’s state or federal income tax return, three consecutive months of payroll stubs, or benefit statements from wherever you obtain your income.
Section D: Signature
This is of course where you sign the Assurance Wireless Application. But it’s more than just a signature. You are certifying that you are telling the truth. Don’t cheat. Here is the exact wording you are agreeing to by signing the application:
By signing below, I certify under penalty of perjury that the information contained within this application is true and correct and that I am head of my household. I also acknowledge that providing false or fraudulent documentation in order to receive assistance is punishable by law and the penalties of perjury include monetary fines and potential imprisonment.
I understand that completion of this application does not constitute immediate approval for Assurance Wireless service. I authorize Assurance Wireless or its duly appointed representative to access any records (including financial records) required to verify my statements herein and to confirm my eligibility for Assurance Wireless service. I authorize social service agency representatives to discuss with and/or provide information to Assurance Wireless verifying my participation in public assistance programs that qualify me for Assurance Wireless service. I also authorize Assurance Wireless to release any records (including financial records) required for the administration of Assurance Wireless service.
I understand that I may be required to verify my continued eligibility for Assurance Wireless service at any time. Failure to verify eligibility will result in termination of Assurance Wireless service. In the future, if my total household income exceeds 135% of the federal poverty guidelines, or I am no longer eligible to receive benefits from at least one of the qualifying public assistance programs listed above, I will notify Assurance Wireless within five (5) days.
I understand that Lifeline Assistance is only available for one landline or wireless phone per household. If I currently have a Lifeline plan with a different phone service provider, I will notify my current provider when I am approved for Assurance Wireless service.