FCC 5629 Lifeline Program Application Form

PROPOSED FCC FORM 5629

OMB APPROVAL EDITION 3060-0819

Lifeline Program
Application Form

1.
About
Lifeline
Lifeline is a federal
benefit that lowers the
monthly cost of phone
or internet service.

Rules
If you qualify, your household can get Lifeline for phone or internet service, but not both.

• I f you get Lifeline for phone service, you can get the benefit for one mobile phone or one home
phone, but not both.

• I f you get Lifeline for internet service, you can get the benefit for your mobile phone or your home
connection, but not both.

• I f you get Lifeline for bundled phone and internet service, you can get the benefit for your mobile
phone bundled service or your home bundled service, but not both.

Your household cannot get Lifeline from more than one phone or internet company.
You are only allowed to get one Lifeline benefit per household, not per person. If more than one person in
your household gets Lifeline, you are breaking the FCC’s rules and will lose your benefit.

What is a household?
A household is a group of people who live together and share income and expenses (even if they are not
related to each other).

Do not give your benefit to another person
Lifeline is non-transferable. You cannot give your Lifeline benefit to another person, even if they qualify.

Be honest on this form
You must give accurate and true information on this form and on all Lifeline-related forms or questionnaires. If
you give false or fraudulent information, you will lose your Lifeline benefit (i.e., de-enrollment or being barred
from the program) and the United States government can take legal actions against you. This may include (but
is not limited to) fines or imprisonment.

You may need to show other documents
If the Lifeline Program Administrator is not able to prove you or someone in your household qualify using
this form and electronic databases, you may need to show an official document from one of the government
qualifying programs or to prove your annual income. You can submit copies of your official documents with
this application or wait until the Lifeline Program Administrator asks you for them. To add them now, include
the documents in option 1 or option 2 below:

1. I f you qualify through a government program: copies of both sides of your state ID card and an
official document from the programs you are qualifying though (your SNAP card, Medicaid card, etc.)

2. If you qualify through your income: copies of both sides of your state ID card and 3 pay stubs in a
row (or other accepted documents).

Visit lifelinesupport.org to see the full list of accepted documents.

Apply

Bring or mail the form to this address:

To apply for a Lifeline benefit, fill out every
section of this form, initial every agreement
statement, and sign the last page.

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Universal Service Administrative Company | www.usac.org

PROPOSED FCC FORM 5629

OMB APPROVAL EDITION 3060-0819

Lifeline Program
Application Form

2.
Your
Information
All fields are required
unless indicated.

What is your full legal name?

The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

First

Last

Middle (optional)

What is your phone number (if you have one)?

Suffix (optional)

What is your date of birth?

Month

Day

Year

What is your email address (if you have one)?
What are the last 4 numbers of your Social Security Number (SSN)?
(Enter your Tribal Identification Number if you do not have a SSN)

What is the best way to reach you?
email
*Tribal lands include any federally recognized
Indian tribe’s reservation, pueblo, or colony,
including former reservations in Oklahoma;
Alaska Native regions established pursuant to
the Alaska Native Claims Settlement Act (85
Stat. 688); Indian allotments; Hawaiian Home
Lands—areas held in trust for Native Hawaiians
by the state of Hawaii, pursuant to the Hawaiian
Homes Commission Act, 1920 July 9, 1921,
42 Stat. 108, et. seq., as amended; and any
land designated as such by the Commission
for purposes of this subpart pursuant to the
designation process in the FCC’s Lifeline rules.

phone

text message

mail

What is your home address? (The address where you will get service. Do not use a P.O. Box)

Street Number and Name

City

Apt., Unit, etc.

State

Is this a temporary address?

Yes

Zip

No

Check if you live on Tribal Lands*

What is your mailing address? (Only fill this out if it is not the same as your home address.)

Street Number and Name

City

Only fill this section
out if you are applying
through a child or
dependent.

Apt., Unit, etc.

State

Zip

C
 heck if you are qualifying through a child or dependent in your household.
If so, answer the following questions:
What is their full legal name?

First

Last

Middle (optional)

Suffix

What are the last 4 numbers of their Social Security Number (SSN)?
(Enter their Tribal Identification Number if they do not have a SSN)
Check if they live on Tribal Lands

What is their date of birth?

Month

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Day

Year

Universal Service Administrative Company | www.usac.org

PROPOSED FCC FORM 5629

OMB APPROVAL EDITION 3060-0819

Lifeline Program
Application Form

3.
Qualify for
Lifeline
Fill out this section to
show that you, your
dependent, or someone
in your household
qualifies for Lifeline.
You can qualify through
some government
assistance programs or
through your income (you
do not need to qualify
through both).

Qualify through a government program:
Check all programs that you or someone in your household have:
Supplemental Nutrition Assistance Program (SNAP) (Food Stamps)
Supplemental Security Income (SSI)
Medicaid
Federal Public Housing Assistance (FPHA)
Veterans Pension or Survivors Benefit Programs
Tribal Specific Programs

Bureau of Indian Affairs (BIA) General Assistance

Tribal Temporary Assistance for Needy Families (Tribal TANF)

Food Distribution Program on Indian Reservations (FDPIR)

Tribal Head Start (only households that meet the income qualifying standard)

Or
Qualify through your income:
(Only fill this out if you do not qualify through a government program.)
Including you, how
many people live in your
household? (check one)

Is your income the same or less than the amount listed for your
state and household size?
(only check yes or no next to your household size)

All 48 States & DC

Alaska

Hawaii

(not Alaska and Hawaii)

1

$16,281

$20,331

$18,711

Yes

No

2

$21,924

$27,392

$25,205

Yes

No

3

$27,567

$34,452

$31,698

Yes

No

4

$33,210

$41,513

$38,192

Yes

No

5

$38,853

$48,573

$44,685

Yes

No

6

$44,496

$55,634

$51,179

Yes

No

7

$50,139

$62,694

$57,672

Yes

No

8

$55,782

$69,755

$64,166

Yes

No

If more than 8, add this
amount for each extra person:

$5,643

$7,061

$6,494

Yes

No

135% of the 2017 Federal Poverty Guidelines
*The Federal Poverty Guidelines are typically updated at the end of January.

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Universal Service Administrative Company | www.usac.org

PROPOSED FCC FORM 5629

OMB APPROVAL EDITION 3060-0819

Lifeline Program
Application Form

4.
Agreement
I agree, under
penalty of perjury,
to the following
statements:
You must initial next to
each statement.

Initial

I (or my dependent or other person in my household) currently get benefits from the government
program(s) listed on this form or my annual household income is 135% or less than the Federal
Poverty Guidelines (the amount listed in the Federal Poverty Guidelines table on this form).
I agree that if I move I will give my service provider my new address within 30 days.

Initial

Initial

Initial

Initial

Initial

Initial

Initial

Initial

I understand that I have to tell my service provider within 30 days if I do not qualify for Lifeline
anymore, including:
1) I , or the person in my household that qualifies, do not qualify through a government
program or income anymore.
2) E
 ither I or someone in my household gets more than one Lifeline benefit (including, more
than one Lifeline broadband internet service, more than one Lifeline telephone service, or
both Lifeline telephone and Lifeline broadband internet services).
I know that my household can only get one Lifeline benefit and, to the best of my knowledge, my
household is not getting more than one Lifeline benefit.
I agree that my service provider can give the Lifeline Program administrator all of the information I
am giving on this form. I understand that this information is meant to help run the Lifeline Program
and that if I do not let them give it to the Administrator, I will not be able to get Lifeline benefits.
A
 ll the answers and agreements that I provided on this form are true and correct to the best of
my knowledge.
I know that willingly giving false or fraudulent information to get Lifeline Program benefits is
punishable by law and can result in fines, jail time, de-enrollment, or being barred from the
program.
M
 y service provider may have to check whether I still qualify at any time. If I need to recertify
(renew) my Lifeline benefit, I understand that I have to respond by the deadline or I will be
removed from the Lifeline Program and my Lifeline benefit will stop.
I was truthful about whether or not I am a resident of Tribal lands, as defined in section 2 of this
form.

Signature

5.
Agent
Information
Answer only if a sales
person submits this form.

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Today’s Date

What is the agent’s full legal name?

The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

First

Last

What is the agent’s USAC ID number?

Middle (optional)

Suffix

What is the agent’s date of birth?

Month

Day

Year

Universal Service Administrative Company | www.usac.org

PROPOSED FCC FORM 5629

OMB APPROVAL EDITION 3060-0819

Lifeline Program
Application Form

Notice
PAPERWORK REDUCTION ACT NOTICE: Section 54.410 of the Federal Communications Commission’s rules requires all
Lifeline subscribers to demonstrate their eligibility to receive Lifeline services. This collection of information stems from the
Commission’s authority under Section 254 of the Communications Act of 1934, as amended, 47 U.S.C. §254. Using this authority,
the FCC has designated USAC as the permanent Lifeline Administrator. The FCC has published rules detailing how consumers can
qualify for Lifeline services and what Lifeline services they may receive (47 CFR §54.400 et seq.). The data provided in response to
this information collection will be used by USAC to verify the applicant’s eligibility for Lifeline services.
We have estimated that each response to this collection of information will take, on average, between 0.25 and 0.75 hours. Our
estimate includes the time to read the questions, look through existing records, gather the required data, and actually complete
and review the form or response. If you have any comments on this estimate, or how we can improve the collection and reduce
the burden it causes you, please write to the Federal Communications Commission, OMD-PERM, Paperwork Reduction Project
(3060-0819), Washington, D.C. 20554. We also will accept your comments via the Internet if you send them to [email protected]. Please
DO NOT SEND COMPLETED DATA COLLECTION FORMS TO THIS ADDRESS.
Remember – You are not required to respond to a collection of information sponsored by the Federal government, and the
government may not conduct or sponsor this collection, unless it displays a currently valid Office of Management and Budget
(OMB) control number. This collection has been assigned an OMB control number of 3060-0819.
The Commission is authorized under the Communications Act of 1934, as amended, to collect the information we request on
this form. If we believe there may be a violation or potential violation of a statute or a Commission regulation, rule, or order,
your response may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing, or
implementing the statute, rule, regulation, or order.
If you do not provide the information we request on this form, you will not be eligible to receive Lifeline services under the Lifeline
Program rules, 47 C.F.R. §§ 54.400-54.423.
The foregoing Notice is required by the Paperwork Reduction Act of 1995, P.L. No. 104-13, 44 U.S.C. § 3501, et seq.
PRIVACY ACT STATEMENT: The Privacy Act is a law that requires the Federal Communications Commission (FCC) and the
Universal Service Administrative Company (USAC) to explain why we are asking individuals for personal information and what we
are going to do with this information after we collect it.
Authority: Section 254 of the Communications Act (47 U.S.C. § 254), as amended, 47 U.S.C. §254, authorizes the FCC to operate
the Lifeline program. Using this authority, the FCC has designated USAC as the permanent Lifeline Administrator. The FCC has
published rules detailing how consumers can qualify for Lifeline services and what Lifeline services they may receive (47 CFR
§54.400 et seq.).
Purpose: We are collecting this personal information so we can verify that you qualify for the Lifeline program and so we can
efficiently provide Lifeline services to you. We access, maintain and use your personal information in the manner described in the
Lifeline System of Records Notice (SORN), FCC/WCB-1, which we have published in 82 Fed. Reg. 38686 (Aug. 15, 2017).
Routine Uses: We may share the personal information you enter into this form with other parties for specific purposes, such
as: with contractors that help us operate the Lifeline program; with other federal and state government agencies that help
us determine your Lifeline eligibility; with the telecommunications companies that provide you Lifeline service; and with law
enforcement and other officials investigating potential violations of Lifeline rules.
A complete listing of the ways we may use your information is published in the Lifeline SORN described in the “Purpose”
paragraph of this statement.
Disclosure: You are not required to provide the information we are requesting, but if you do not, you will not be eligible to receive
Lifeline services under the Lifeline Program rules, 47 C.F.R. §§ 54.400-54.423.

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Universal Service Administrative Company | www.usac.org