California Lifeline Renewal Form Sample Page 3
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4California LifeLine Program
RESPONSE DATE: 03/22/2017
RENEWAL FORM
Step 2
INITIAL HERE
By printing my initials here, I certify that no one else in my household is receiving
California LifeLine discounts with my current phone company or another phone company
(including federal Lifeline for cell phone service).
Step 3
PROGRAM-BASED: Are you or is anyone in your household, including kids, enrolled in any of the programs
listed below? If YES, fill in the bubble with a blue or black pen next to all of the programs in which you or any
household member(s) are enrolled. Fill in bubble completely. Sample:
Correct
Incorrect
Tribal TANF
Women, Infants, and Children Program (WIC)
Head Start Income Eligible (Tribal Only)
Medicaid/Medi-Cal
Bureau of Indian Affairs General Assistance
Supplemental Security Income (SSI)
Food Distribution Program on Indian Reservations
National School Lunch Program (NSLP)
(FDPIR)
Low Income Home Energy Assistance Program
Temporary Assistance for Needy Families (TANF),
(LIHEAP)
California Work Opportunity and Responsibility to
CalFresh, Food Stamps, or Supplemental
Kids (CalWORKs), Stanislaus Work Opportunity
Nutrition Assistance Program (SNAP)
and Responsibility to Kids (StanWORKs),
Welfare-to-Work (WTW), or Greater Avenues for
Federal Public Housing Assistance or Section 8
Independence (GAIN)
Federal Veterans and Survivors Pension
Benefit Program
If you filled in any bubble on Step 3, skip Step 4.
STOP
Step 4
INCOME-BASED: Is your household’s total annual gross income at or less than the annual income
limits? Check the Income Table in the Eligibility Guidelines.
How many people (adults and kids) are in your household?
Adults (18 and over)
Kids (under 18)
What is your household’s total annual gross income? (Round to whole dollars.)
$
0 0
,
.
Check the Income Calculator in the Eligibility Guidelines.
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