iFoster - LifeLine Phone Program Application

iFoster - LIFELINE Program Overview

Program Overview

Lifeline is a government benefit program. This program is not administered by iFoster - we assist youth in foster care with application and approval for the program. Lifeline service is supported by the federal Universal Service fund and your State Public Utility Commission. For more information about Lifeline and eligibility, go here: https://www.lifelinesupport.org/ If you meet the eligibility requirements for this program and have not been enrolled previously you will receive a Android smart phone with talk, text and data for Free. The amount of service provided in talk, text and data will be determined by which state you live in.

Instructions to Apply 1) Complete and submit this application and release of information.

2) Lifeline requires a copy of your: - Copy of Medicaid Card (front and back) - Copy of Birth certificate - Signed copy of your social security card - Proof of address (State ID that matches service address, energy water or internet bill) The most secure way to submit these documents is through the iFoster Digital Locker. To access the Digital Locker, sign up for FREE membership at iFoster.org. You can also email them to sarah@ifoster.org. 3) iFoster will review your paperwork and submit your application to the State Carrier Partner and then to the appropriate State Lifeline Administrator.

Eligibility

- 18 years of age or older to apply

- Provide all documentation requested above

- Look at https://www.lifelinesupport.org/ for additional details about eligibility

APPLICANT INFORMATION

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Last Four Digits of Social Security Number

Phone

Referring Agency (if one)

Home/Shipping Address: If living in a residential or dorm setting, please provide last home address if that address can also be used as shipping address.

Shipping Address (Street Address)

Apartment or Unit Number (n/a if none)

City

State

Postal Code

Will you or your Supportive Adult be at this address for the next 30 days?

Questionnaire

1) Are you living in any of the following housing arrangements? (Check all that apply)

With someone you would consider to be a roommate, this may include a relative (i.e. sibling, cousin, grandparent)With foster parentsIn a group homeIn temporary housing provided by County or a Foster Care AgencyIn a dormIn a frat or sorority houseIn a shelter

2) Are you claimed as a dependent on anyone else's tax return?

YesNo

3) Do you currently receive Medicaid benefits?

YesNo

3a) If you do not receive Medicaid benefits, did you leave foster care on or after your 18th birthday

YesNo

Instructions & Information Release

I authorize iFoster to release to, and discuss with the iFoster's program partners for Lifeline cell phone service, any of the below listed information required to apply for the specific program or programs I want. By submitting my completed application form and selecting "yes", I authorize iFoster to act on my behalf and enroll me in the program, to share necessary personal information from the required uploaded documents, and to provide me with regular updates on the status of my application. iFoster will only share the minimum required information needed to apply for the specific program you want. iFoster will not share any information with partners for programs you do not specifically request iFoster to apply for on your behalf.

Yes

I understand my rights:
1) I authorize the disclosure of the above indicated information for the purpose listed. This information Release Consent is voluntary.
2) I have the right to revoke this information Release in writing to iFoster (email, fax or mail). The Information Release will stop on the date my request is received, except for action already taken, or if this Information Release was obtained as a condition of insurance, enrollment or eligibility.
3) I understand that I am signing this Information Release voluntarily and there are many iFoster programs that I have access to which do not require the release of information. I understand that I will continue to have access to these programs if I choose to not sign this release. However, there may be some programs which I will not have access to since these programs require some, if not all, the above requested information.

Thank you! iFoster will review your paperwork and submit your application to our State Carrier Partner and then to the appropriate State LifeLine Administrator. We will keep you updated on the progress of your application in posts to your My Account on the iFoster Portal. To access My Account, sign up for a free membership at iFoster.

Pending approval, a phone will be mailed to you in 7-10 business days!

Any questions can be sent to Sarah at Sarah@ifoster.org or call 855-936-7837