FCC Form 497

OMB Approval

Edition 3060-0819

Lifeline/Low Income Universal Service

Description of One-Per-Household Worksheet 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 One-Per-Household Worksheet

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	Home address	Applicant will supply home address including street number and name, apartment number, city, state and zip code.
3	Live with other adult indicator	Applicant will check a box to indicate whether they live with an adult age 18 or older.
4	Household member receiving Lifeline indicator	Applicant will check a box to indicate whether the adult they live with receives a Lifeline benefit.
5	Sharing income/expenses indicator	Applicant will check a box to indicate whether they share income and expenses with the adult they live with.
6	Worksheet result	The applicant will check one of three boxes to indicate the result of their worksheet selections, which will either indicate “You can apply for Lifeline” or “You do not qualify for Lifeline”.
7	Agreements	Applicant will initial 1-2 agreements that they understand and agree to the one-per-household rule in accordance with Section 54.410(g) of the Lifeline rules.
8	Signature	Applicant will sign the application.
9	Date	Applicant will date the application.