free house phone lifeline
Lifeline Home Phone

Lifeline Forms


Lifeline government assisted phone service requires a signed Lifeline Certification form be submitted before the order can be processed.

If you placed your order on-line, your lifeline certification was submitted during that process.
If you ordered service over the phone, you'll need to complete and submit a form here. Many states have an on-line form that can be done by logging into the customer portal. If available for your state, you may use this method by clicking your state in the table below.
If you prefer, or if a customer portal isn't available for your state, click youor state in the second table below which will brin up a printable, pdf form. Print then fill out this form and return it to us.

Click your state for the proper form:
Alabama Indiana Ohio
Arkansas Louisiana South Carolina
California Michigan  
Colorado Mississippi Tennessee
Florida Missouri Texas
Printable pdf Forms
Alabama Kentucky Oklahoma
Arkansas Louisiana South Carolina
Florida Michigan  
Georgia Mississippi Tennessee
Indiana Missouri Texas
Kansas North Carolina Wisconsin
Use one of the following to return the completed form to us.
  • Fax it to 1-866-700-4736.
  • Scan it into your computer and email it to
  • Take a close-up, high resolution photo then Text it to (Just enter this email address into the "To" field where the phone number would normally go)
  • Mail it to the address on the form.
  • Upload it

Government Assisted Home Phone Service

Limited Time Promotions!

  • Free to Start*
  • Free Month of Service*
  • Free Long Distance
  • Free Activation

More Information

*For lifeline qualified customers (participating in government assistance) in the AT&T areas. Not available in all states.

Free Cell Phone Plans

free gov cell phone

Would you like to get lifeline assistance on a wireless phone plan instead of home phone?

You can get up to 1000 free minutes per month on a government assisted cell phone for free if you qualify for Lifeline.

More Information

Lifeline assistance is permitted on just on phone per household. You cannot receive Lifeline assistance on your mobile phone if you already receive it on your home phone.