Information Collection

FCC Form 497 and instructions - individuals or households

IC 201445 under ICR 201308-3060-005 · OMB 3060-0819.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-0819 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FCC Form 497 FCC Form 497 and instructions - individuals or households	Form and Instruction
FCC Form 497 Lifeline Worksheet 0819_FCC497_090412.docx	Form and Instruction

IC Title:

FCC Form 497 and instructions - individuals or households

Agency IC Tracking Number:

WCB

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 47 CFR 54.400 - 54.707 47 CFR 54.202 47 CFR 54.410(f) 47 CFR 54.416(b) 47 CFR 54.422(a)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FCC Form 497	Lifeline Worksheet	0819_FCC497_090412.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 940

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 35 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	11,280	11,280
Annual IC Time Burden (Hours)	28,200	28,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.