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Elevate IMPACT Plan Application

First name

Last name

Middle name

Date of birth

Phone

Service address line 1

Service address line 2

City

State

Zip

Do you have a different mailing address?

Yes

Proof of eligibility

To qualify for your Elevate IMPACT discount you must provide proof of current eligibility from one of the following programs. Please attach a copy with this application.

• SNAP • Medicaid

• Federal Pell Grant

• Veterans Pension and Survivors Benefit Program

• Federal Housing Program

• Supplemental Security Income (SSI)

• WIC

• Lifeline

Signature

By submitting this application, you agree to the following: Residential Terms of Service & Acceptable Use Policy. Elevate reserves the right to discontinue this program at any time. If governmental funding sources are re-established, Elevate may discontinue the IMPACT plan and serve as a participating provider in the governmental program(s).