Flebotomia

®

Enrollment Number: 8089883

REQUIRED FLORIDA APPLICATION FORM LIFELINE ASSISTANCE PROGRAM
SECTION I
Date: 11/07/2011
Please make sure that you provide correct personal information. Yourinformation will be validated against Public Records and any discrepancies could result in delays in your application approval. 1. PLEASE PRINT name and physical residence address of person applying forassistance: Del Toro Last Name Raul First Name 3053866568 C Middle Home Phone Number Initial

Cell-Phone Number 6207 SW 131ST CT APT 104 Street / Apartment No.

Contact Phone Numberbaicon2000@yahoo.com E-mail MIAMI City 2464 Last 4 digits of SSN FL State 33183-5286 Zip Code 12/02/1927 Birth Date
250 Free Monthly Minutes

Plan Features Choose your plan (check one)

68 Free MonthlyMinutes

125 Free Monthly Minutes

Local Calls National Long Distance Voicemail Nationwide Text Roaming at no Additional Cost Free 911 411 Directory Assistance at no Additional Cost Carry-Over Minutesfrom Month to Month 100+ International Long Distance Destinations*

(0.3 minutes per text)

(1 minute per text)

(1 minute per text)

**

*List of Destinations available at www.Safelink.com**If you choose this plan, your unused minutes will be removed/wiped out and will not carry-over on your next monthly minutes delivery. However, if you purchase and redeem additional minutes cards,all unused minutes will carry-over for three consecutive months.

SECTION II
I hereby certify that I participate in at least ONE of the following public assistance programs (select just ONE programfrom the list): Medicaid Supplemental Nutrition Assistance Program (Food Stamps) Temporary Assistance for Needy Families (TANF) Supplemental Security Income (SSI) National School Lunch Program (NSLP)- Free Lunch Low-Income Home Energy Assistance Program (LIHEAP) Federal Public Housing Assistance/Section 8 Bureau of Indian Affairs Programs (Tribal Temporary Assistance for Needy Families, Head...