Information Collection

Individuals or Households

IC 218852 under ICR 202012-3060-004 · OMB 3060-0819.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-0819 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FCC Form 5629 Individuals or Households	Form
Lifeline Form Change Memo (01.27).docx	Other-Form Change Memo
PRA Template Form 481 2.3.2020 (clean).docx	Other-Template Form 481
FCC Form 5629 Lifeline Application Universal Form LI_App_UniversalForm5629-Jan2020_v3.pdf	Form
FCC 497 Lifeline Worksheet FCC-Form-497.pdf	Form and Instruction

IC Title:

Individuals or Households

Agency IC Tracking Number:

WCB

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 47 CFR 54.201-54.207 47 CFR 54.400-54.423

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FCC Form 5629	Lifeline Application Universal Form	LI_App_UniversalForm5629-Jan2020_v3.pdf	Yes	Yes	Fillable Fileable Signable
Other-Form Change Memo			Lifeline Form Change Memo (01.27).docx	Yes	Yes	Fillable Fileable Signable
Other-Template Form 481			PRA Template Form 481 2.3.2020 (clean).docx	Yes	Yes	Fillable Fileable Signable
Form and Instruction	FCC 497	Lifeline Worksheet	FCC-Form-497.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records

Title: FCC/WCB - 1, Lifeline Program

FR Citation: 82 FR 38686

Number of Respondents: 9,167,887

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	10,051,118	10,051,118
Annual IC Time Burden (Hours)	4,265,927	4,265,927
Annual IC Cost Burden (Dollars)	468,750	468,750

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.