2025 Lifeline Mobility Client Application

BRAG Lifeline Mobility | Client Application

July 1, 2025 to June 30, 2026
Complete and submit the following application with all verification documentation and any correlating forms if there is not enough space to provide the requested information. Applications are reviewed in 5-10 business days. Additional documents may be requested during this time. Requested documents are due within 10 business days or the application will be closed. Qualified applicants will proceed to an intake. For questions, assistance completing the application or to request an accommodation, contact the mobility specialist.
Applicant Name*
Application Date*

MonthDayYear
Date
Address*

Home Address

Street Address Line 2

CityState

Zip

Lifeline Mobility I Client Application

July 1, 2025 to June 30, 2026
SELF-DECLARATION OF HOUSEHOLD INCOME

Complete the household income and deduction table for the previous month. Use empty slots if two people have the same type of income or other income types. Proof of income documentation must be included with this application. Gross income for all household members must be disclosed or the application will be denied. Medical expenses, child support and alimony paid are eligible deductions. Proof of payment for expenses must be attached to be considered.
Reporting Month:
MONTHLY HOUSEHOLD INCOME

All types must be filled out and all adults must appear below including those that did not earn income. Use $0.00 and NONE when applicable. Example 1: Employment/Self-Employment, $1,500, BRAG, Jane Smith. Example 2: Adult Receiving No Income, $0.00, None, John Smith.
Employment/Self Employment
Amount Received Income Source Household Member
Unemployment
Amount Received Income Source Household Member
Workers Compensation
Amount Received Income Source Household Member
Social Security
Amount Received Income Source Household Member
Pension/Retirement
Amount Received Income Source Household Member
Veteran Benefits
Amount Received Income Source Household Member
Alimony
Amount Received Income Source Household Member
Child Support
Amount Received Income Source Household Member
Assistance from Family/Friends
Amount Received Income Source Household Member
Adult Receiving No Income
Household Member
Other or Repeat Type of Income |
Income Type Amount Received Income Source Household Member
Other or Repeat Type of Income |
Income Type Amount Received Income Source Household Member
I need additional space to provide other income sources

YesNo

Additional Income Sources
Additional Income
Income Type Amount Received Income Source Household Member
Additional Income
Income Type Amount Received Income Source Household Member
Additional Income
Income Type Amount Received Income Source Household Member
Additional Income
Income Type Amount Received Income Source Household Member
Additional Income
Income Type Amount Received Income Source Household Member
Additional Income
Income Type Amount Received Income Source Household Member

Document Upload
Proof of Household Income Documentation:

Upload documentation showing the last 30-days income for all household members.
Cancelof

MONTHLY HOUSEHOLD DEDUCTIONS
MONTHLY HOUSEHOLD DEDUCTIONS

This section is optional and only needs to be completed to have expenses removed from the household income. Example 1: Prescription Medication, $20, Wal-Mart, Jane Smith. Example 2: Child Support, $1500, Karen Ward, John Smith. Note documentation must be attached for an expense to be an eligible deduction. More more than 3 deductions write this information on the additional receipts and upload them.
Expense Description
Dollar Amount Paid Expense Paid To Expense Paid By
Expense Description
Dollar Amount Paid Expense Paid To Expense Paid By
Expense Description
Dollar Amount Paid Expense Paid To Expense Paid By
I need additional space to provide more monthly expenses.

YesNo

Additional Monthly Expenses
Additional Expense
Expense Description Dollar Amount Paid Expense Paid To Expense Paid By
Additional Expense
Expense Description Dollar Amount Paid Expense Paid To Expense Paid By
Additional Expense
Expense Description Dollar Amount Paid Expense Paid To Expense Paid By
Additional Expense
Expense Description Dollar Amount Paid Expense Paid To Expense Paid By
Additional Expense
Expense Description Dollar Amount Paid Expense Paid To Expense Paid By
Additional Expense
Expense Description Dollar Amount Paid Expense Paid To Expense Paid By
Additional Expense
Expense Description Dollar Amount Paid Expense Paid To Expense Paid By
Additional Expense
Expense Description Dollar Amount Paid Expense Paid To Expense Paid By
Additional Expense
Expense Description Dollar Amount Paid Expense Paid To Expense Paid By
Additional Expense
Expense Description Dollar Amount Paid Expense Paid To Expense Paid By
Additional Expense
Expense Description Dollar Amount Paid Expense Paid To Expense Paid By

Proof of Payment Documentation

Upload proof of payment for each deduction to be considered.
Cancelof

All household members that are not a minor/dependent need to sign. Warning: Title 18, Section 1001 of the United States Code, states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the United States.
Applicant Signature*

Clear
Applicant Signature

Clear
Should be Empty:

BRAG Lifeline Mobility | Client Application

BRAG Lifeline Mobility I Client Application

Lifeline Mobility I Client Application

MONTHLY HOUSEHOLD INCOME

MONTHLY HOUSEHOLD DEDUCTIONS