Step One Completed (Required) I have completed step 1. (Required) 2 Check the appropriate box then fill out this form: Existing or New Customer (Required)
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.
3 Fill out your information below. Name (Required)
Date of Birth (Required) Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Mailing Address
(Required) Service Type (Required) Internet Phone Internet and Phone Terms and Conditions (Required) I have read the Terms and Conditions This 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 LifelineACP@coastconnect.com. 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.