Lifeline Program Referral Form Affordable phone and internet for Wisconsin households.Please complete the following short form to help us connect you to a Lifeline Navigator on our team.Quick Links:More about Lifeline CompanyThis field is for validation purposes and should be left unchanged.Name(Required) First Last Address(Required)This will help us better with finding Lifeline providers who may be available in your area. Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) How did you hear about this program?(Required)Note/Comment:This is optional in case you have a question. Or please let us know if you have a preference on how or when you would like us to contact you.
