Galaxy Lifeline

First Name *

Last Name *

Last 4 digits of your Social Security Number *

Birth Date *

Street Address *

Apartment or Unit Number

City *

State *

Zipcode *

Permanent

Temporary

Street Address

Apartment or Unit Number

City

State

Zipcode

Select Government Program *

Yes

National Verifier Application ID Not Required

iOS

Android

Click to upload your government ID
Not Required

Click to upload your Proof of Benefit
Not Required

I agree, under penalty of perjury,to the following statements:

(You must initial next to each statement.)

Typing your name in the box below will be considered your signature

TYPE NAME

I agree to the terms of service and privacy policy.

Verify benefits and delivery through SMS

I acknowledge that my PII will be transferred to NLAD to complete my Lifeline enrollment.