Billing Assistance You may be eligible for payment assistance through the Lifeline federal program. Lifeline CoastConnect subscribers could receive a monthly credit of up to $9.25 toward their bill. To see if you qualify, follow these three steps: X/TwitterThis field is for validation purposes and should be left unchanged.Step 1: Apply at nationalverifier.servicenowservices.com/lifeline. (After completing your application return to this page and check this box.)Step One Completed(Required) I have completed step 1.(Required)Step 2: Check the appropriate box then fill out this form:Existing or New Customer(Required) Existing CoastConnect subscriber Not yet receiving service from CoastConnect, but plan to sign up Before you fill out this form, make sure you have your Lifeline Application ID handy. You must complete the fields in the form exactly as you did for the Lifeline application, otherwise it may delay applying the credit to your account.Step 3: Fill out your information below.Name(Required) First Middle Last Suffix Lifeline Application ID(Required)Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Last 4 Digits of your Social Security Number(Required)Name of Child/Dependent Receiving the Benefit: First Last Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Service Type(Required)InternetPhoneInternet and PhonePhone(Required)Email(Required) Terms and Conditions(Required) I have read the Terms and ConditionsThis signed Lifeline Enrollment Form (“Enrollment Form”) is required to enroll you in CoastConnect’s Lifeline program. The National Verifier, not CoastConnect, determines your eligibility to receive Lifeline. Only persons who have been determined to be eligible by the National Verifier should complete this Enrollment Form: If you have not qualified for Lifeline through the National Verifier, please visit https://nationalverifier.service-now.com/lifeline to apply or complete and submit your paper application. The information you enter on this Enrollment Form must be the same as what you provided to the National Verifier. Lifeline is a government assistance program to reduce your phone and/or broadband internet bill, from service with any participating service provider of your choosing. You cannot transfer your service benefit to someone else and only eligible consumers may enroll in the program. The program is limited to one discount per household, which is defined as any individual or group of individuals who live together at the same address and share income and expenses. If I qualify for another government assistance program (such as the Affordable Connectivity Program), I understand that I may choose to participate in both programs with CoastConnect, although I am not required to do so. CoastConnect’s general and Lifeline Terms and Conditions of service apply to existing or newly activated service (A copy may be obtained by visiting www.CoastConnect.com). CoastConnect offers Lifeline services only in areas where it has been designated as an Eligible Telecommunications carrier. If you have any questions, disputes, concerns, or complaints regarding CoastConnect’s Lifeline program, please contact us at 877.969.3884 or at [email protected].BENEFIT TRANSFER REQUEST I currently receive Lifeline benefits from another carrier and I request that CoastConnect submit a Benefit Transfer on my behalf. I understand that I will only receive Lifeline benefits from CoastConnect and will lose my benefits from my current service provider.CERTIFICATION(Required) I authorize government agencies and their authorized representatives to discuss with, receive from, and provide information to CoastConnect that is relevant to my eligibility to receive Lifeline benefits from CoastConnect. I acknowledge that CoastConnect will, and I give my consent from CoastConnect to, use my personal information such as my name, address, telephone number, the date on which Lifeline service is initiated, the date on which Lifeline service is terminated, the amount of support being sought, the means through which I qualify for Lifeline, and any information provided in this form, to verify and document my eligibility to receive Lifeline benefits with the Universal Service Administrative Company (USAC), to ensure the proper administration of the Lifeline program. I understand that failure to provide consent will result in my being denied the Lifeline service. I further certify that to the best of my knowledge, no one in my household is already receiving a Lifeline service.Consent(Required) I acknowledge that I have read this disclosure about the Lifeline program.Lifeline is a service offered as part of a government assistance program and is available only to eligible consumers that qualify through their participation in other government programs or through income. It is a non-transferable service and limited to one benefit per household. Visit www.CoastConnect.com for details. CoastConnect is a subsidiary of Coast Electric Power Association.After you click submit, you will be redirected to CoastConnect sign up page, where you can select which of our lightning-fast speeds you need.
