FCC Form 497

OMB Approval

Edition 3060-0819

Lifeline/Low Income Universal Service

Description of Lifeline ETC Reimbursement Data Fields

(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 States participating in NLAD

Item Number	Field Description	Purpose/Instructions
1	Service Provider Identification Number (SPIN)	Unique 9-digit number that USAC uses to identify service providers.
2	Study Area Codes (SAC) included in this claim	This is the unique USAC identifier(s) for the ETC submitting the filing.
3	Service Month (from drop down)	To create a unique identifier for this submission to determine which month the data is being filed.
4	Initial Certification: ETCs will certify, pursuant to 47 C.F.R. §§ 54.403 and 54.407, that it has passed through the support received to the qualifying low-income consumer. ETCs must also state that they are in compliance with all of the Lifeline Program rules, and to the extent required, have obtained valid certification and recertification forms from each of the subscribers for whom they are seeking reimbursement. Furthermore, carriers must file revisions to reimbursement requests on a rolling twelve-month window basis.	Requires an ETC to certify that the ETC verifies consumer eligibility prior to enrolling a consumer in Lifeline and passes the support received on to the associated low income consumers.
5	List of reimbursable NLAD IDs active for service month that are associated with the claiming ETC.	To identify customers who can potentially be claimed for reimbursement, USAC will share a list of active NLAD IDs for that ETC. The ETC must return a list with all subscribers for each month. Alternatively, the ETC can submit its own data file containing all data listed in these data fields.
6	Amount claimed for each subscriber, including Enhanced Tribal support.	ETC will identify the amount of reimbursement for each subscriber for the month and include Enhanced Tribal support.
7	Link Up amount claimed for each subscriber.	ETC will identify the amount of Link Up reimbursement for each subscriber.
8	Total ETC reimbursement for the service month	This is the sum of all amounts claimed for subscribers for the service month. Field will pre-populate based on the amount claimed per subscriber.
9	Reason code for subscribers not being claimed.	For those subscribers the ETC is no longer claiming, ETC will indicate the reason using a reason code
10	(Optional field) ETC Identifier	ETCs have the option to add a unique identifier in addition to the NLAD ID if it helps match subscribers in their billing systems.
11	(Optional field) Subscriber’s first name	Some ETCs need additional customer data to match data in their billing systems. This field will support that matching.
12	(Optional field) Subscriber’s last name	Some ETCs need additional customer data to match data in their billing systems. This field will support that matching.
13	(Optional field) Subscriber address	Some ETCs need additional customer data to match data in their billing systems. This field will support that matching.
14	(Optional field) Subscriber city	Some ETCs need additional customer data to match data in their billing systems. This field will support that matching.
15	(Optional field) Subscriber state	Some ETCs need additional customer data to match data in their billing systems. This field will support that matching.
16	(Optional field) Subscriber zip code	Some ETCs need additional customer data to match data in their billing systems. This field will support that matching.
17	(Optional field) Subscriber phone number	Some ETCs need additional customer data to match data in their billing systems. This field will support that matching.
18	(Optional field) Subscriber date of birth	Some ETCs need additional customer data to match data in their billing systems. This field will support that matching.
19	(Optional field) Service type	ETCs can indicate whether service is voice, data, or bundled service.
20	(Optional field) Subscriber social security number last four digits	Some ETCs need additional customer data to match data in their billing systems. This field will support that matching.
21	(Optional field) Information on whether the subscriber is Tribal or non-Tribal	ETC will indicate if the subscriber is Tribal or non-Tribal
22	Additional Certifications: The ETC’s certifying officer will certify that based on the information known to them or provided to them by employees responsible for the preparation of the data being submitted, they certify under penalty of perjury that the data contained in the form has been examined and reviewed and is true, accurate, and complete. The ETC’s certifying officer must acknowledge the Fund Administrator’s authority to request additional supporting information as may be necessary.	ETC’s certifying officer must certify the company has examined and reviewed the data and that it is true, accurate and complete.
23	Certifying Officer Signature	ETC’s certifying officer must sign to certify the company listed is in compliance with all federal Lifeline certification procedures.
24	Printed Name and Title of Officer	This is the name of the authorized person certifying the form.
25	Email Address of Officer	This is the email address of the authorized person signing the form.
26	Date	User must provide the date form was completed. This field will be pre-populated.
27	Person Completing Form	This is the name of the authorized person completing the form if different than the officer certifying the form.
2	Contact Phone Number	User must provide phone contact information for the authorized person completing the form.

Fields for States that do not participate in NLAD

Item Number	Field Description	Purpose/Instructions
1	Service Provider Identification Number (SPIN)	Unique 9-digit number that USAC uses to identify service providers.
2	Study Areas Codes (SAC) included in this claim	This is the unique USAC identifier(s) for the ETC submitting the filing.
3	Service Month (from drop down)	To create a unique identifier for this submission to determine which month the data is being filed.
4	Initial Certification: ETCs will certify, pursuant to 47 C.F.R. §§ 54.403 and 54.407, that it has passed through the support received to the qualifying low-income consumer. ETCs must also state that they are in compliance with all of the Lifeline Program rules, and to the extent required, have obtained valid certification and recertification forms from each of the subscribers for whom they are seeking reimbursement. Furthermore, carriers must file revisions to reimbursement requests on a rolling twelve-month window basis.	Requires an ETC to certify that the ETC verifies consumer eligibility prior to enrolling a consumer in Lifeline and passes the support received on to the associated low income consumers.
5	ETC Identifier	ETCs have the option to add a unique identifier if it helps match subscribers in their billing systems.
6	List of subscribers eligible for reimbursement.	If information is available from state data sources, USAC will provide ETC with a list of subscribers believed to be eligible for reimbursement. The ETC must return a list with all subscribers for each month. Otherwise, the ETC will submit its own data file containing all data listed in these data fields.
7	Subscriber’s first name	Additional customer data is needed to match data in the ETC’s billing systems. This field will support that matching.
8	Subscriber’s last name	Additional customer data is needed to match data in the ETC’s billing systems. This field will support that matching.
9	Subscriber address	Additional customer data is needed to match data in the ETC’s billing systems. This field will support that matching.
10	Subscriber city	Additional customer data is needed to match data in the ETC’s billing systems. This field will support that matching.
11	Subscriber state	Additional customer data is needed to match data in the ETC’s billing systems. This field will support that matching.
12	Subscriber zip code	Additional customer data is needed to match data in the ETC’s billing systems. This field will support that matching.
13	Subscriber phone number	Some ETCs need additional customer data to match data in their billing systems. This field will support that matching.
14	Subscriber date of birth	Some ETCs need additional customer data to match data in their billing systems. This field will support that matching.
15	Subscriber social security number last four digits	Some ETCs need additional customer data to match data in their billing systems. This field will support that matching.
16	Service type	ETC will need to provide service type (i.e. voice, data, or bundled service)
17	Amount claimed for each subscriber including Enhanced Tribal support.	ETC will identify the amount of reimbursement for each subscriber for the month and include Enhanced Tribal support.
18	Amount of Link Up support claimed for each subscriber.	ETC will identify the amount of Link Up reimbursement for each subscriber for the month.
19	Information on whether the subscriber is Tribal or non-Tribal	ETC will identify whether the subscriber is Tribal or non-Tribal
20	Total ETC reimbursement for the service month	This is the sum of all amounts claimed for subscribers for the service month. This field will be pre-populated based on the amount claimed per subscriber.
21	Reason code for subscribers not being claimed.	For those subscribers the ETC is no longer claiming, ETC will indicate the reason using a reason code
22	Additional Certifications: The ETC’s certifying officer will certify that based on the information known to them or provided to them by employees responsible for the preparation of the data being submitted, they certify under penalty of perjury that the data contained in the form has been examined and reviewed and is true, accurate, and complete.	ETC’s certifying officer must certify the company has examined and reviewed the data and that it is true, accurate and complete.
23	Certifying Officer Signature	ETCs certifying officer must sign to certify the company listed is in compliance with all federal Lifeline certification procedures.
24	Printed Name and Title of Officer	This is the name of the authorized person certifying the form.
25	Email Address of Officer	This is the email address of the authorized person signing the form.
26	Date	User must provide the date form was completed. This field will be pre-populated.
27	Person Completing Form	This is the name of the authorized person completing the form if different than the officer certifying the form.
28	Contact Phone Number	User must provide phone contact information for the authorized person completing the form.