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Step 1 of 5: Personal Info (0% completed)
Name *
Date of Birth *
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Is this a rural address? *
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How do you qualify for Lifeline service in Arizona?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Arizona? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Subscribers that reside on Tribal lands may be eligible for additional benefits. If you reside on Tribal lands, please complete the certification below. (required*)
Please select your Tribe below. (required*)
Which tribal plan do you like? (required*)
Which non-tribal plan do you like? (required*)

How do you qualify for Lifeline service in Colorado?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Colorado? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Subscribers that reside on Tribal lands may be eligible for additional benefits. If you reside on Tribal lands, please complete the certification below. (required*)
Which tribal plan do you like? (required*)
Which non-tribal plan do you like? (required*)

How do you qualify for Lifeline service in Hawaii?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Hawaii? (required*)
Qualifying Programs OR Income Based Eligibility in Hawaii?

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG HI
Household Size Income
1 $18,455
2 $24,881
3 $31,307
4 $37,733
5 $44,159
6 $50,585
7 $57,011
8 $63,464
For each additional person add $6,453

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Subscribers that reside on Tribal lands (also known as Hawaiian Home Lands) may be eligible for additional benefits. If you reside on Tribal lands or Hawaiian Home Lands, please complete the certification below. (required*)
Which tribal plan do you like? (required*)
Which tribal plan do you like? (required*)
Which non-tribal plan do you like? (required*)
Which non-tribal plan do you like? (required*)

How do you qualify for Lifeline service in Kentucky?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Kentucky? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Which plan do you like? (required*)
Silly question, huh? We still need to check.

How do you qualify for Lifeline service in Michigan?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Michigan? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 150% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 150% FPG
Household Size Income
1 $17,820
2 $24,030
3 $30,240
4 $36,450
5 $42,660
6 $48,870
7 $55,095
8 $61,335
For each additional person add $6,240

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Subscribers that reside on Tribal lands may be eligible for additional benefits. If you reside on Tribal lands, please complete the certification below. (required*)
Which tribal plan do you like? (required*)
Which non-tribal plan do you like? (required*)

How do you qualify for Lifeline service in Minnesota?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Minnesota? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Subscribers that reside on Tribal lands may be eligible for additional benefits. If you reside on Tribal lands, please complete the certification below. (required*)
Which tribal plan do you like? (required*)
Which non-tribal plan do you like? (required*)

How do you qualify for Lifeline service in Missouri?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Missouri? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Which plan do you like? (required*)

How do you qualify for Lifeline service in North Dakota?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in North Dakota? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Subscribers that reside on Tribal lands may be eligible for additional benefits. If you reside on Tribal lands, please complete the certification below. (required*)
Which tribal plan do you like? (required*)
Which non-tribal plan do you like? (required*)

How do you qualify for Lifeline service in Nevada?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Nevada? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Subscribers that reside on Tribal lands may be eligible for additional benefits. If you reside on Tribal lands, please complete the certification below. (required*)
Which tribal plan do you like? (required*)
Which non-tribal plan do you like? (required*)

How do you qualify for Lifeline service in Oklahoma?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Oklahoma? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Subscribers that reside on Tribal lands may be eligible for additional benefits. If you reside on Tribal lands, please complete the certification below. (required*)
Which tribal plan do you like? (required*)
Which tribal plan do you like? (required*)

How do you qualify for Lifeline service in Pennsylvania?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Pennsylvania? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Which plan do you like? (required*)

Consumers have the right to contact the Pennsylvania Bureau of Consumer Services at 1-800-692-7380 if complaints brought to Blue Jay's Customer Service Department are not resolved.

How do you qualify for Lifeline service in Puerto Rico?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Puerto Rico? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Which plan do you like? (required*)

How do you qualify for Lifeline service in Rhode Island?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Rhode Island? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Subscribers that reside on Tribal lands may be eligible for additional benefits. If you reside on Tribal lands, please complete the certification below. (required*)
Which tribal plan do you like? (required*)
Which non-tribal plan do you like? (required*)

How do you qualify for Lifeline service in South Carolina?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in South Carolina? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Subscribers that reside on Tribal lands may be eligible for additional benefits. If you reside on Tribal lands, please complete the certification below. (required*)
Which tribal plan do you like? (required*)
Which non-tribal plan do you like? (required*)

How do you qualify for Lifeline service in Texas?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Texas? (required*)

In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below. Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616
Beneficiary's Step 2 of 5: Personal Information
Date of Birth (required*)
Date of Birth:
Which plan do you like? (required*)

How do you qualify for Lifeline service in Utah?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Utah? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Subscribers that reside on Tribal lands may be eligible for additional benefits. If you reside on Tribal lands, please complete the certification below. (required*)
Which tribal plan do you like? (required*)
Which non-tribal plan do you like? (required*)

How do you qualify for Lifeline service in Wisconsin?

Step 2 of 5: Personal Info › Qualify (20% completed)
Qualifying Programs OR Income Based Eligibility in Wisconsin? (required*)

Please enter your total household income. In order to be eligible, your household income must be at or below 135% the Federal Poverty Guidelines. The annual income requirements for your state are listed below.

Qualifying Annual Income Amounts – 135% FPG
Household Size Income
1 $16,038
2 $21,627
3 $27,216
4 $32,805
5 $38,394
6 $43,983
7 $49,586
8 $55,202
For each additional person add $5,616

Our team will double check your response after you submit your application to make sure your income meets the federal requirements.

Beneficiary's first and last name (required*)
Beneficiary's date of birth (required*)
Subscribers that reside on Tribal lands may be eligible for additional benefits. If you reside on Tribal lands, please complete the certification below. (required*)
I certify under penalty of perjury. (required*)
Which tribal plan do you like? (required*)
Which non-tribal plan do you like? (required*)

Almost there! Please read and accept the
Disclosures & Certifications below.

Step 3 of 5: Personal Info › Qualify › Disclosures (40% completed)

A complete and signed Lifeline Certification Form ("Certification") is required to enroll you in the Lifeline Program in your state. This Certification is only for the purpose of verifying your eligibility for Lifeline service and will not be used for any other purpose. Service requests will not be processed until this Form has been received and verified by Blue Jay Wireless. Check each box to agree.

Please read and check each box to state your agreement:

I hereby certify, under penalty of perjury, that (initial by checking each box):

Confirm Household Eligibility

Step 4 of 5: Personal Info › Qualify › Disclosures › Household Eligibility (60% completed)

Lifeline is a government assistance program. A household may not receive multiple Lifeline discounts. You may apply your Lifeline discount to either one landline or one wireless number, but you cannot have the discount on both and you cannot receive Lifeline benefits from multiple providers.

A household is defined, for purposes of the Lifeline program, as any individual or group of individuals who live together at the same address and share income and expenses. An adult is any person 18 years of age or older, or an emancipated minor (a person under age 18 who is legally considered to be an adult). Household expenses include food, health care expenses, and other living expenses.

Income means gross income (income before taxes and deductions) for all members of the household, from all sources.

Do you live at an address occupied by multiple households? (required*)
Do you have a husband, wife, or domestic partner living at your address and receiving Lifeline-discounted phone service? (required*)
You are not eligible because someone in your household already has Lifeline service.
Does another adult (age 18 or older) or emancipated minor live with you AND have Lifeline service? For example, a parent, child, relative, roommate, or another person? (required*)
Does this person share expenses for bills, food, or other living expenses AND share income with you? (required*)
You are not eligible because someone in your household already has Lifeline service.
(Initial by checking the box.)
Date/Time

Final Step! Upload Qualifying Proof

Step 5 of 5: Personal Info › Qualify › Disclosures › Household Eligibility › Proof (80% completed)

Get a Free Smart Phone!

Upload your documents within 3 hours of applying to automatically upgrade your phone to a smart phone.

That's the Blue Jay Way!

File uploads may not work on some mobile devices.

Fax Number

Email Address

Mailing Address

800.305.5308

sales@bluejaydocs.com

Blue Jay Wireless, Enrollment

4240 International Pkwy, Suite 140,

Carrollton, TX 75007

You can provide either a benefits card, an official award letter, or another official document that shows you receive benefits from the qualifying program that you selected on page 2 of the application.

File uploads may not work on some mobile devices.
File uploads may not work on some mobile devices.
Date/Time

Please use this field to enter the telephone number of the person who referred to you Blue Jay Wireless. Be sure to include the word "Voice" or "Data" after the telephone number to tell us if the reward should be voice minutes or data.

Promotional Options (optional)

Your security is very important to us. Once you have submitted your application, please close this window of your internet browser to ensure your data cannot be viewed by anyone else.

By clicking 'Submit' you acknowledge that the information you provided as part of this enrollment form serves as an electronic signature and that you agree that Blue Jay may contact you regarding this application.