Attachment B-4 The Free Cell Phone & Minutes Program

Dear SafeLink Customer:

You are invited to participate in a yearlong test provided by SafeLink Wireless. We will give you free Internet service for e-mailing, web browsing and more, all from a new WiFi hotspot that will be sent to you. You must possess a device, such as a , or tablet to participate.

Here’s what you need to do to get started with this free program.

1. Complete/Fill out the enclosed application

2. Sign/Date the application

3. Return/Mail back the application to SafeLink Wireless

This free Internet program will be provided to a limited number of customers. Please send back your application as soon as possible to guarantee your participation. Once you are enrolled, we will send you your new WiFi hotspot in the mail with instructions to get started.

Thank you for your participation and we look forward to providing you another great service from the SafeLink Wireless family.

Sincerely,

The SafeLink Team

758461

THE SAFELINK BROADBAND PROGRAM APPLICATION

John Q. Sample Enrollment ID 12345 Main Street City, ST 97222-2222 Project Code Identifier IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII

Please answer the questions below. Sign, date and mail back this form in the enclosed prepaid envelope.

What is your age: Do you subscribe to broadband currently? o Yes Number of Household members who will be using the o No subsidized service: Have you subscribed to broadband in the past? o Never o Within last 3 months Ages of household members: o Within last 6 months o Within last 12 months In 2011, what was this household’s total income before taxes? o More than 12 months ago o Less than $5,000 o $20,001-$30,000 o $5000-$9999 o $30,001 or more If you previously subscribed to broadband, but dropped o $10,000-$20,000 o Not Determined service, reason for dropping: (Can choose more than one response, Answer NA if previous Equipment expected to be used with broadband service: answer is “Never” ) (Can choose more than one response) o Monthly cost too expensive o Desktop Computer o Didn’t use service o Laptop/netbook computer o The equipment no longer worked o Tablet o Don’t know how to use computer/Internet o Mobile device () o Uncomfortable with Internet (e.g. privacy concerns, o (aircard) dangerous for children) o Happy with dial-up Reason(s) for use of Internet o Could access Internet elsewhere (Can choose more than one response) o NA o Want to stay in touch with family and friends o Children need it for school Reasons for not previously obtaining broadband: o Subscriber needs it for school (Can choose more than one response) o Want to access music o Monthly cost too expensive o Movies and other entertainment o Didn’t use service o Children want o Don’t know how to use computer/Internet o Get health care or medical information o Uncomfortable with Internet (e.g. privacy concerns, o Job required online access dangerous for children) o Need it for job searches o Happy with dial-up o Want to share photos or videos with family and friends o Could access Internet elsewhere o Internet provider oered a good price for the service o Other (specify) o Use for daily activities (e.g. check bus schedule) o Other (specify)

Terms: You must possess a device, such as a laptop, netbook or tablet to participate. You will receive 2GB of data for up to 12 months. Periodically we will need to contact you to gather information about your data usage. All of your information will be used anonymously. YES, I’d like to participate in this program! Signature: Date:

758613 Attachment F 3easy steps FULL CERTIFICATION APPLICATION FOR WASHINGTON LIFELINE ASSISTANCE PROGRAM

SECTION 1 Provide only correct personal information. It will be validated against Public Records, any discrepancies will result in Rejection of service. Qualifying Address Mailing Address (if different from your Qualifying Address)

Address/Apt. No.

City

State Zip code

*First Name MI *Last Name Select if address is temporary: o * Provide only correct personal information. *Birth Date (Month/Day/Year) *Last Four Digits of SSN DSHS Client ID (9 Digits) It will be validated against Public Records.

Contact Phone Number Email Address

50 6688tos 2tos 5tos 68 125 2502 Minu 112125Minu 2502Minu Plan Features nthhlylyy thhlly yy nthhlyly yy Características del plan TIS TIS TIS MontMonthly MontMonthlyon s MMontMonthlyteess GRA GRA s GRA Choose your plan (check one) minutes minutes minutes Escoja su plan (marque uno) cada mes cada me cada mes Local Calls Llamadas Locales National Long Distance Larga Distancia Nacional Voice Mail Buzón de Voz Nationwide Text (0.3 minutes per text) (1 minute per text) (1 minute per text)t) Mensajes de Texto Nacional (0.3 min. por texto) (1 min. por texto) (1 min. por texto)) Roaming at no Additional Cost Roaming sin Costo Adicional Free 911 911 Gratis 411 Directory Assistance at no Additional Cost Asistencia de Directorio 411 sin Costo Adicional Carry-Over Minutes from Month to Month ** Minutos Transferibles Mes a Mes ** 100+ International Long Distance Destinations* Llamadas Internacionales a Más de 100 Destinos* * List of destinations available at www.SafeLink.com * Lista de destinos disponible en www.SafeLink.com ** If you choose this plan, your unused minutes will be removed/wiped out and will not carry-over on your next monthly minutes delivery. However, if you purchase and redeem additional minutes ** Si elige este plan, todos los minutos que no use serán removidos/borrados y no se acumularán en la próxima entrega de minutos. Sin embargo, si compra y carga tarjetas de minutos adicionales, todos los cards, all unused minutes will carry over for three consecutive months. minutos que no use se acumularán hasta tres meses consecutivos. T PT T PT OPTION OPTIONP OPCIÓN OPCIÓN OPTION OPTIONP OPCIÓN OPCIÓN SECTION1 Select2 ONE of the two options below (Proof of1 eligibility2 MUST1 be submitted2 for either option, name and address1 must match2 applicant). 2 Select ONE of the two options below (Proof of eligibility MUST be submitted for either option, name and address must match applicant). Qualify by certifying you belong3 to ONE of the programs listed below, Qualify by checking the3 number of people in your family and your monthly 3EASY programsQualify bywith certifying (*) DO NOT you requirebelongPASOS proof.to ONE Remaining of the programs3EASY programs listed require below, Qualifyincome, by checking attach proof the numberPASOS of income of people such in asyour last family year’s and Federal your monthly or State income, Income attach Tax proof of SIMPLES income such as last year’sSIMPLES Federal or State Income Tax return, a Social Security statement of benefit, a STEPS OPTION OPTION OPCIÓNSTEPS OPCIÓN OPTION OPTION OPCIÓN OPCIÓN OPTION anand award attach letter proof,OPTION from such SSA asor astate copy agency of a Medicaid stating thator Food you StampreceiveOPTION the OPTION letterreturn, from a yourSocial employer, Security pay statement stubs from of 3 consecutivebenefit, a lettermonths, from an Unemployment your employer, or Workmen’spay 1 benefit,Card, a orletter a similar from1 SSAofficial or state document. agency Provide stating Copies that you ONLY receive the Compensationstubs from 3 statement consecutive of benefits, months, a Retirement/Pension an Unemployment statement or Workmen’s of benefits Compen or a divorce- benefit, or a similar document. Provide Copies ONLY 2 2 decree,sation child statement support of award, benefits, or other a officialRetirement/Pension document containing statement income of information.benefits Provideor o Community Options Program Entry System (COPES)* Copiesa divorce ONLY decree, child support award, or other official document containing o Disability Lifeline (formerly General Assistance)* income information. Provide Copies ONLY oo DSHS Medicaid Chore Service* Persons in Family or Household Annual Income Monthly Income SECTION SECTION SECTION SECTION SECTION SECTION oo Medical Supplemental Assistance Nutrition (Medicaid)* AssistanceSECCIÓN ProgramSECCIÓN (SNAP)SECCIÓN Food Stamps 1 SECCIÓN $15,080SECCIÓN SECCIÓN$1,257 1 2 3 1 2 1 3 2 3 2 1 $20,426 2 $1,7023 oo Refugee Supplemental Assistance* Security Income (SSI) 0 3 5 $25,772 $2,148 80tos 2tos 5tos o State Family Assistance (SFA)* 80 125 2502 Minu 112125Minu 250252Minu lyy lyy lyy TISTIS TIS oPlan Federal Features Public Housing Assistance (Sectionnthhly 8) onthhl yy 4 ntn hhly y $31,118 $2,593 Características del plan o Supplemental Nutrition Assistance ProgramMonthlyMont (SNAP)s Food Stamps* MontMonthlys MMontMonthlyteess GRAGRA GRA GRATIS Choose your plan (check one) minutes minutes 5 minutes Escoja su plan (marque uno) cada mes cada mes cada mes o Supplemental Low-Income SecurityHome Energy Income Assistance (SSI)* Program (LIHEAP) $36,464 $3,039 o Local Calls 6 $41,810 $3,484 Llamadas Locales oo NationalTemporary National Long SchoolDistanceAssistance Lunch for Program’sNeedy Families free program (TANF)* only 7 $47,156 $3,930 Larga Distancia Nacional o VoiceFederal Mail Public Housing Assistance (Section 8) Buzón de Voz o Temporary Assistance for Needy Families (TANF) 8 $52,502 $4,375 o NationwideLow-Income Text Home Energy Assistance Program (0.3 minutes(LIHEAP) per text) (1 Forminute each additionalper text) person, add: (1 $5,346minute per text)t) $446 Mensajes de Texto Nacional (0.3 min. por texto) (1 min. por texto) (1 min. por texto)) o RoamingNational at Schoolno Additional Lunch Cost Program’s free lunch program Roaming sin Costo Adicional * ProgramsFree 911 are validated by a state agency (No Proof required) 911 Gratis 411 Directory Assistance at no Additional Cost Asistencia de Directorio 411 sin Costo Adicional SafeLink® isCarry-Over a Lifeline Minutes supported from service. Month to Lifeline Month is a federal benefit, and only eligible subscribers may enroll. Customers who willfully ** make false statements in order to obtain Minutos Transferibles Mes a Mes ** the benefit100+ can Internationalbe punished Long by fine Distance or imprisonment Destinations* or can be barred from the program. Llamadas Internacionales a Más de 100 Destinos* * List of destinations available at www.SafeLink.com * Lista de destinos disponible en www.SafeLink.com Lifeline is available** If you choose for only this plan, one your line unused per household. minutes will be A removed/wiped household isout defined and will not as carry-overany individual on your next or group monthly of minutes individuals delivery. who However, live if together you purchase at and the redeem same additional address minutes and share income ** Si elige este plan, todos los minutos que no use serán removidos/borrados y no se acumularán en la próxima entrega de minutos. Sin embargo, si compra y carga tarjetas de minutos adicionales, todos los and expenses. cards, A householdall unused minutes is not will permitted carry over for to three receive consecutive Lifeline months. benefits from multiple providers. Violation of the one-per-household rule constitutes a violation of FCC rules, minutos que no use se acumularán hasta tres meses consecutivos. and will result in the Customer’s disenrollment from Lifeline. Lifeline is a non-transferable benefit, and a Customer may not transfer his or her benefit to another person. o Check this box if you would like to receive pre-recorded special offers and promotional offers from TracFone at the Contact Telephone number provided above.

o REFERRED BY A FRIEND: Customer’s First Name Customer’s Last Name SafeLink Phone Number

SECTION You MUST check off (a) all statements, then Sign and Date application. (Your application cannot be approved without these items) 3 I certify under penalty of perjury to each of the following: o I participate in the above designated qualifying program OR have income at or below the level specified above. o I understand that I must notify SafeLink® within 30 days if I no longer participate in the qualifying program or meet the income eligibility threshold, if I or another member of my household obtains Lifeline supported service from another carrier, or, for any other reason, I no longer qualify for Lifeline support. o I understand I may be required to recertify my continued eligibility for Lifeline at any time, and failure to do so will result in termination of my Lifeline benefits. o If I change my address, I will provide my new address to SafeLink® within 30 days. o My household will receive only one Lifeline benefit and to the best of my knowledge, my household is not already receiving a Lifeline service. o The information contained in this application is true and accurate to the best of my knowledge, and I acknowledge that providing false or fraudulent information to obtain Lifeline benefits is punishable by law. o

off MUST be checked Boxes I agree to cancel my current service or Washington Telephone Assistance Program service in favor of SafeLink Wireless® prior to applying for the Lifeline service. I authorize Safelink Wireless® or its duly appointed representative to: (1) access any records required to verify my statements herein; (2) to confirm my continued eligibility for Lifeline assistance; (3) to update my address to a proper mailing address format; (4) to provide my name, telephone number, and address to the Universal Service Administrative Company (USAC) (the administrator of the program) and/or its agents for the purpose of verifying that I do not receive more than one Lifeline benefit; and (5) I authorize DSHS to disclose or give access to confidential information about me for one year from the date of this application for the purpose of determining my eligibility for Lifeline assistance. By signing below, I separately affirm and agree to each of the above statements.

Applicant Signature Date For questions please call 1-800-SafeLink (1-800-723-3546) Fax application to: 1-866-902-5756 Promo Code: Mail application to: SafeLink Wireless® w PO Box 220009 w Milwaukie, OR 97269-0009 565605 14741-WA Income App English