FCC Form 5629 Lifeline Program Application Form

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OMB 3060-0819
Est. Time Per Response: 45 min

FCC FORM 5629

Lifeline Program
Application Form

1.
About
Lifeline
Lifeline is a Federal
Communications
Commission (FCC)
program that provides
a monthly phone or
internet service discount
for qualifying low-income
consumers.

Rules
If you qualify, your household can receive a monthly Lifeline benefit of up to $9.25 to lower the costs of
phone or internet service and up to $34.25 for qualifying households on Tribal lands.
• If you get Lifeline for phone service, you can get the benefit for one mobile phone or one home
phone, but not both.
• If you get Lifeline for internet service, you can get the benefit for your mobile phone or your home
connection, but not both.
• If 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.

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). Complete the Lifeline household worksheet to determine if more than one qualifying
household is located at your address. If more than one person in your household participates in Lifeline, you
are breaking the FCC’s rules and will lose your benefit.

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 validate that you or someone in your household qualify
by checking available electronic resources (including eligibility databases for the FCC’s government agency
partners), you may need to provide additional documents. For example, you may need to provide an official
document that proves your participation in a qualifying government assistance program, your income, or
your identity. Please include copies of your proof documentation when you submit your application to
speed up processing time.

Apply
To apply for a Lifeline benefit, fill out the required
sections of this form, initial every agreement
statement, and sign on page 6. You can also apply
online at LifelineSupport.org for fastest processing.
Page 1 of 8

Mail the form to this address:
USAC
Lifeline Support Center
P.O. Box 9100
Wilkes-Barre, PA 18773

Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473

OMB 3060-0819
Est. Time Per Response: 45 min

FCC FORM 5629

Lifeline Program
Application Form

2a.
Your
Information
All fields are required
unless indicated. Use only
CAPITALIZED LETTERS
and black ink to fill out
this form.
*The Safe Connections Act (SCA)
was enacted to ensure that survivors
can separate from abusers without
losing independent access to their
mobile service. Through the SCA,
survivors can receive a 6-month
benefit by providing proof of a
legitimate line separation request
submitted to a service provider
and confirming that they are
experiencing financial hardship. A
survivor is defined as an individual
who is not less than 18 years old
and either (1) experienced domestic
violence, dating violence, sexual
assault, stalking, sex trafficking,
or (2) cares for someone who
has experienced such acts. If
participating through the SCA,
consumers can list an address from
the last 6 months. It does not have
to be your current address.

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

Middle (optional)

Suffix (optional)

Last

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

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)?
If you do not have a SSN, what is your Tribal Identification Number?

Check if you are applying as a Survivor of Domestic Violence under the SCA (Safe Connections Act)*:
What is the best way to reach you?
email

phone*

text message*

mail

*If I selected the phone or text option, I consent to let USAC contact me at my Lifeline phone
number for important reminders and updates to my Lifeline service.
If I selected the text message option, message and data rates may apply.
Text STOP to end messages.

Page 2 of 8

Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473

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Est. Time Per Response: 45 min

FCC FORM 5629

Lifeline Program
Application Form

2b.
Your
Information
(continued)
*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 FCC for
purposes of this subpart pursuant
to the designation process in the
FCC’s Lifeline rules.
A map of qualifying Tribal lands is
available on USAC’s website:
https://www.lifelinesupport.org/
wpcontent/uploads/documents/getlifeline/fcc_tribal_lands_map.pdf

Page 3 of 8

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

Street Number and Name

Apt., Unit, etc.

State

City

Zip Code

Is this a temporary address?

Yes

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

Apt., Unit, etc.

State

City

Zip Code

Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473

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Est. Time Per Response: 45 min

FCC FORM 5629

Lifeline Program
Application Form

2c.
Your
Information
(continued)
Only fill this section
out if you are applying
through a child or
dependent.

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

Middle (optional)

Suffix (optional)

Last

What is their date of birth?

Month

Day

Year

What are the last 4 numbers of their Social Security Number (SSN)?
If they do not have a SSN, what is their Tribal Identification Number?

Page 4 of 8

Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473

OMB 3060-0819
Est. Time Per Response: 45 min

FCC FORM 5629

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
certain government
assistance programs or
through your income (you
do not need to qualify
through both).
When you mail this
form, please include
documents that show
you participate in
one of the programs
you selected or that
you qualify through
your income. A list of
acceptable documents
is available at
LifelineSupport.org

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
Survivors of Domestic Violence through the Safe Connections Act (SCA) - must also complete
Section 5 on page 7
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)

Qualify through your income:

Or

(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,
and Territories
(not Alaska and Hawaii)

Alaska

Hawaii

1

$20,331

$25,394

$23,369

Yes

No

2

$27,594

$34,479

$31,725

Yes

No

3

$34,857

$43,565

$40,082

Yes

No

4

$42,120

$52,650

$48,438

Yes

No

5

$49,383

$61,736

$56,795

Yes

No

6

$56,646

$70,821

$65,151

Yes

No

7

$63,909

$79,907

$73,508

Yes

No

8

$71,172

$88,992

$81,864

Yes

No

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

Add $7,263

Add $9,086

Add $8,357

Yes

No

135% of the 2024 Federal Poverty Guidelines
*The Federal Poverty Guidelines are typically updated at the end of January.

Page 5 of 8

Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473

OMB 3060-0819
Est. Time Per Response: 45 min

FCC FORM 5629

Lifeline Program
Application Form

4.
Agreement
I agree, under
penalty of perjury,
to the following
statements:
You must initial next to
each statement. If you fail
to initial each statement,
your application will be
considered incomplete.

Initial

I agree that if I move I will give my service provider my new address within 30 days.
Initial

Initial

Initial

By providing a phone number,
you consent to letting USAC
contact you at that phone
number via artificial or
prerecorded voice message or
text for important reminders
and updates about your Lifeline
benefit. For text messages,
message and data rates may
apply. Text STOP to end messages.

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).

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 all of the information I provide on this form may be collected, used, shared, and retained
for the purposes of applying for and/or receiving the Lifeline Program benefit. I understand that
if this information is not provided to the Lifeline Program Administrator, I will not be able to get
Lifeline benefits. If the laws of my state or Tribal government require it, I agree that the state or
Tribal government may share information about my benefits for a qualifying program with the
Lifeline Program Administrator. The information shared by the state or Tribal government will be
used only to help find out if I can get a Lifeline Program benefit.
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.
The certification below applies to all consumers and is required to process your application.

Initial

I was truthful about whether or not I am a resident of Tribal lands, as defined in section 2 of
this form.

Signature

Page 6 of 8

Today’s Date

Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473

OMB 3060-0819
Est. Time Per Response: 45 min

FCC FORM 5629

Lifeline Program
Application Form

5.
Survivors
of Domestic
Violence
Domestic Violence
Survivors can qualify for
an emergency Lifeline
benefit through the
Safe Connections Act
(SCA) by (A) providing
evidence of a legitimate
line separation request
submitted to the provider,
and (B) confirming their
participation in a broader
range of qualifying
programs or that their
income is at or below 200%
of the Federal Poverty
Guidelines.

Qualify as a Survivor of Domestic Violence:
(Only fill this out if you qualify as a Survivor of Domestic Violence)
Check all programs that you or someone in your household have:
Federal Pell Grant for the current award year
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Free and Reduced-Price School Lunch or Breakfast Program, or enrollment in a Community Eligibility
Provision School

Or
Certify your income by completing the chart below.
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,
and Territories
(not Alaska and Hawaii)

Alaska

Hawaii

1

$30,120

$37,620

$34,620

Yes

No

2

$40,880

$51,080

$47,000

Yes

No

3

$51,640

$64,540

$59,380

Yes

No

4

$62,400

$78,000

$71,760

Yes

No

5

$73,160

$91,460

$84,140

Yes

No

6

$83,920

$104,920

$96,520

Yes

No

7

$94,680

$118,380

$108,900

Yes

No

8

$105,440

$131,840

$121,280

Yes

No

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

Add $10,760

Add $13,460 Add $12,380

Yes

No

200% of the 2024 Federal Poverty Guidelines
*The Federal Poverty Guidelines are typically updated at the end of January.

Initial

Initial

Initial

Page 7 of 8

I have received documentation from my service provider that I submitted a legitimate line
separation request, and I am submitting my application with evidence of that documentation.
I f my eligibility cannot be confirmed automatically, or if I do not have proof of my income, I certify
under penalty of perjury that my income is at or below 200% of the Federal Poverty Guidelines,
and I am experiencing financial hardship (only to be completed if documentation cannot be easily
provided).
I understand that by qualifying for Lifeline through the Safe Connections Act (SCA), I am eligible
for the benefit for 6 months. I understand that once the 6 month benefit period is over, I may
qualify for Lifeline through participation in another qualifying program or by confirming my initial
income is at or below 135% of the Federal Poverty Guidelines.
Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473

FCC FORM 5629

OMB APPROVAL EDITION 3060-0819

Lifeline Program
Application Form

6.

Representative
Information
Representatives who
help consumers apply
(such as phone or internet
company agents, state
and Tribal partners, etc.)
are required to register
in the Representative
Accountability Database
(RAD) and must enter their
information in this section.

What is your Representative ID?

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 FCC’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. In certain cases, the information in your form may be disclosed to the
Department of Justice, court, or other adjudicative body when (a) the Commission; (b) any employee of the Commission; or (c)
the United States government, is a party to a proceeding before the body or has an interest in the proceeding.
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, is available at https://www.fcc.gov/managing-director/privacytransparency/
privacy-act-information#systems/.
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.

Page 8 of 8

Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473