FCC Form 497

OMB Approval

Edition 3060-0819

Lifeline/Low Income Universal Service

Description of Application for Lifeline Program

(Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual representation of what each applicant will see).

Fields for Lifeline Universal Application

Item Number	Field Description	Purpose/Instructions
1	Full legal name	Applicant will supply first name and last name with optional middle name and suffix.
2	(Optional field) Phone number	Applicant has option to supply phone number.
3	Date of birth	Applicant will supply month, day and year of birth for purpose of identity verification.
4	(Optional field) Email address	Applicant has option to supply email address for program correspondence.
5	Last 4 digits of Social Security number or tribal ID	Applicant will supply the last 4 digits of their social security number or their full tribal ID for identity verification.
6	Preferred contact method	Applicant will check box for email, phone, text message or mail to indicate their preferred contact method.
7	Home address	Applicant will supply home address including street number and name, apartment number, city, state and zip code.
8	Temporary address indicator	Applicant will check box to indicate whether address is temporary.
9	Tribal lands indicator	Applicant will check box to indicate that they live on Tribal lands.
10	(Optional field) Mailing address	Applicant will supply mailing address only if it is different than their home address.
11	User name and Password (if applicable) – National Verifier States Only	Applicant will enter a user name and Password in order to create an account in the National Verifier system
12	Security Questions (if applicable) – National Verifier States Only	Applicant till enter three security questions for association with their National Verifier account
13	(Optional field) Benefit qualifying person (BQP) indicator	Applicant will check box to indicate they are applying on behalf of a dependent.
14	(Optional field) BQP full legal name	Applicant will supply BQP's first name, last name and have the option to supply a middle name and suffix.
15	(Optional) BQP last 4 digits of Social Security number or tribal ID	Applicant will supply BQP’s last 4 digits of their social security number or their full tribal ID for identity verification.
16	(Optional field) Tribal land indicator	Applicant will check a box to indicate that the BQP lives on tribal lands
17	(Optional field) BQP date of birth	Applicant will supply the BQP's month, day and year of birth.
18	Qualifying program indicator	Applicant will check a box indicating in which Lifeline qualifying programs they participate.
19	Documentation demonstrating eligibility based on qualifying program (If applicable) – National Verifier States Only	If applicant’s eligibility cannot be automatically verified using an available database, applicant will be asked to upload documentation demonstrating participation in a qualifying program.
20	Income qualification	If applicant does not participate in a Lifeline qualifying program, they will check a box to indicate their household size and household income to indicate that they will qualify using income.
21	Documentation demonstrating eligibility based on income (If applicable) – National Verifier States Only	Applicant will be asked to upload documentation demonstrating eligibility based on income, if applicable.
22	Qualifying program for Benefit Qualifying person (If applicable)	Applicant will indicate in which Lifeline qualifying programs the Benefit Qualifying Person participates, if applicable.
23	Documentation demonstrating eligibility of Benefit Qualifying Person (If applicable) – National Verifier States Only	If the Benefit Qualifying person’s eligibility cannot be automatically verified using an available database, applicant will be asked to upload documentation demonstrating eligibility.
24	Documentation verifying identity (If applicable) – National Verifier States Only	If, as part of the eligibility verification process, the applicant’s identity cannot be verified, applicant will be asked to upload documentation that can be used to verify their identity.
25	Documentation verifying address (If applicable) – National Verifier States Only	If, as part of the eligibility process, the applicant’s address cannot be verified, applicant will be asked to upload documentation that can be used to verify their identity.
26	Documentation of a port-freeze exception (If applicable) – National Verifier States Only	If, as part of the eligibility process, the applicant is determined to be under a port-freeze, which would prevent them from transferring service, applicant will be asked to upload documentation that can verify they have a port-freeze exception.
27	Documentation of emancipated minor status (If applicable) – National Verifier States Only.	If, as part of the eligibility process, the applicant is determined to be under the age of 18 but is an emancipated minor, the applicant will be asked to upload documentation that demonstrates they are an emancipated minor.
28	Certifications	The applicant will initial eight certifications in accordance with Section 54.410(d)(3)(i)–(viii) indicating, under penalty of perjury, that they understand and agree with the rules of the Lifeline program. The applicant will agree that their service provider can give the Lifeline Program administrator all of the information contained on the application form. Applicant will agree that USAC can use the information provided to check applicant’s eligibility. (National Verifier States Only) Applicant will agree that USAC can use the information provided regarding their child or dependent’s information to check applicant’s eligibility (if applicable). (National Verifier States Only)
29	Signature	Applicant will sign the application.
30	Date	Applicant will date the application.

31	(Optional) Agent full legal name	If an agent assisted with the application, agent will supply first and last name with the option of middle name and suffix.
32	(Optional) Agent ID number	If an agent assisted with the application, the agent will supply ID number.
33	(Optional) Agent date of birth	If an agent assisted with the application, agent will supply month, day and year of birth.