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How do you qualify for Lifeline service in Arizona?

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Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Please select your Tribe below. (required*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select a tribal plan below: (required*)
Please select a non-tribal plan below: (required*)

How do you qualify for Lifeline service in Colorado?

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Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select a tribal plan below: (required*)
Please select a non-tribal plan below: (required*)

How do you qualify for Lifeline service in Hawaii?

Personal Info
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Disclosures
Household Eligibility
Proof
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 $18,711
2 $25,205
3 $31,698
4 $38,192
5 $44,685
6 $51,179
7 $57,672
8 $64,166
For each additional person add $6,494

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select a tribal plan below: (required*)
Please select a tribal plan below: (required*)
Please select a non-tribal plan below: (required*)
Please select a non-tribal plan below: (required*)

How do you qualify for Lifeline service in Kentucky?

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Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select plan below: (required*)

How do you qualify for Lifeline service in Michigan?

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Disclosures
Household Eligibility
Proof
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 $18,090
2 $24,360
3 $30,630
4 $36,900
5 $43,170
6 $49,440
7 $55,710
8 $61,980
For each additional person add $6,270

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select a tribal plan below: (required*)
Please select a non-tribal plan below: (required*)

How do you qualify for Lifeline service in Minnesota?

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Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select a tribal plan below: (required*)
Please select a non-tribal plan below: (required*)

How do you qualify for Lifeline service in Missouri?

Personal Info
Qualify
Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select plan below: (required*)

How do you qualify for Lifeline service in North Dakota?

Personal Info
Qualify
Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select a tribal plan below: (required*)
Please select a non-tribal plan below: (required*)

How do you qualify for Lifeline service in Nevada?

Personal Info
Qualify
Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select a tribal plan below: (required*)
Please select a non-tribal plan below: (required*)

How do you qualify for Lifeline service in Oklahoma?

Personal Info
Qualify
Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Please select a tribal plan below: (required*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select a tribal plan below: (required*)

How do you qualify for Lifeline service in Pennsylvania?

Personal Info
Qualify
Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select plan below: (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?

Personal Info
Qualify
Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select plan below: (required*)

How do you qualify for Lifeline service in Rhode Island?

Personal Info
Qualify
Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select a tribal plan below: (required*)
Please select a non-tribal plan below: (required*)

How do you qualify for Lifeline service in South Carolina?

Personal Info
Qualify
Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select a tribal plan below: (required*)
Please select a non-tribal plan below: (required*)

How do you qualify for Lifeline service in Texas?

Personal Info
Qualify
Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643
Beneficiary's Step 2 of 5: Personal Information
Date of Birth (required*)
Date of Birth:
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select plan below: (required*)

How do you qualify for Lifeline service in Utah?

Personal Info
Qualify
Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select a tribal plan below: (required*)
Please select a non-tribal plan below: (required*)

How do you qualify for Lifeline service in Wisconsin?

Personal Info
Qualify
Disclosures
Household Eligibility
Proof
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 $16,281
2 $21,924
3 $27,567
4 $33,210
5 $38,853
6 $44,496
7 $50,139
8 $55,782
For each additional person add $5,643

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*)
I certify under penalty of perjury. (required*)
Select Gadget: (required*)
Choose Watch Color: (required*)

We will do our best to provide the color selected, but will ship what we have in stock.

Use another billing address *
Please select a tribal plan below: (required*)
Please select a non-tribal plan below: (required*)

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

Personal Info
Qualify
Disclosures
Household Eligibility
Proof

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

Personal Info
Qualify
Disclosures
Household Eligibility
Proof

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

Personal Info
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Disclosures
Household Eligibility
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We can request your W2’s or 1099 from the IRS. Please complete the fields below to provide consent:
Do you file taxes jointly with a spouse?

I declare that I am the taxpayer whose name is shown in the fields above.

I declare that I am the taxpayer whose name is shown in the fields above.

Fax Number

Email Address

Mailing Address

800.305.5308

sales@bluejaydocs.com

Blue Jay Wireless, Enrollment

4240 International Pkwy, Suite 140,

Carrollton, TX 75007

Please provide one of the following income-based documents of proof:

  • The prior year’s state, federal or Tribal tax return.
  • Current income statement or paycheck stub from employer.
  • Social Security statement of benefits.
  • Veterans Administration statement of benefits.
  • Retirement or pension statement of benefits.
  • Unemployment or Workers Compensation statement of benefits.
  • Federal or Tribal notice letter of participation in General Assistance.
  • Divorce decree, child support award or other official documentation containing income information.

Note: If the documentation does not cover a full year, such as a current pay stub, the applicant must provide the same type of documentation covering three consecutive months within the previous 12 months.

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.

You’re so smart.

You selected a "Fast Approval Program" on Step 2, therefore we require no further documentation for you to complete your application!
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.

Disclaimer - This is a Lifeline service provided by Blue Jay Wireless, LLC, whichis an eligible telecommunications carrier. (1) Lifeline is a government assistance program. (2) Service is non-transferable. (3) Only one Lifeline discount (wireless or wireline) may be received per household. (4) Only eligible consumers may enroll in the program... Read disclaimer CA disclaimer