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Applicant Information First Name MI Last Name Date of Birth Month Day Year Social Security Number or Tribal ID Number if no SSN XXX-XX-XXXX Contact Telephone Number Residence Address No P. I acknowledge that in addition I may be required to re-certify my continued eligibility at any time and failure to re-certify will result in de-enrollment and termination of my Lifeline benefits. O. Box Initial Here I hereby certify that I participate in at least one of the following programs Check all...
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