California Lifeline Renewal Form Sample Page 2
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4Continue your discounts...RENEW today!
Here’s how:
Check that your personal information is correct.
Step 1
Is your household already getting the California LifeLine discounts?
Step 2
Step 3
Are you a Program-Based participant?
Step 4
Are you an Income-Based participant?
Final
Submit your form online or by mail before the response date.
Step
You do not need to provide any supporting
documentation with your renewal form.
Step 1
Check your name, address, and phone
Call your phone company to report any
number.
mistakes within 30 days. The phone
company will fix them. Corrections on this
sheet will NOT be accepted.
Billing Address
Applicant’s Phone Number:
555-555-5555
JOHN SAMPLE
Anniversary
Date:
123 SAMPLE ST
04/25/2017
SAMPLE CITY, CA 99999
PIN:
1234
CARRIER A’s Phone Number:
777-777-7777
Permanent Service Address
JOHN SAMPLE
123 SAMPLE ST
SAMPLE CITY, CA 99999
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