FCC Form 497

OMB Approval

Edition 3060-0819

Lifeline/Low Income Universal Service

Description of Recertification Form 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 subscriber will see).

Fields for Lifeline Universal Recertification Form

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