Form FCC Form 5630 FCC Form 5630 Lifeline Program Annual Recertification Form

OMB 3060-0819
Est. time per response 0.75
Not yet approved by OMB

FCC FORM 5630

Lifeline Program
Annual Recertification 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
#6,2.2)Ǿ6,2/%,20"%,)! +/" "&3"*,+1%)6&#")&+""+"Ɯ1,#2-1,ʏǞǽǗǚ1,),4"/1%" ,010,#
-%,+",/&+1"/+"10"/3& "+!2-1,ʏǘǙǽǗǚ#,/.2)&+$%,20"%,)!0,+/&))+!0ǽ
• If you get Lifeline for phone serviceǾ6,2 +$"11%""+"Ɯ1#,/,+"*,&)"-%,+",/,+"%,*"
-%,+"Ǿ21+,1,1%ǽ
• If you get Lifeline for internet serviceǾ6,2 +$"11%""+"Ɯ1#,/6,2/*,&)"-%,+",/6,2/
home connection, but not both.
• If you get Lifeline for bundled phone and internet service, 6,2 +$"11%""+"Ɯ1#,/6,2/
*,&)"-%,+"2+!)"!0"/3& ",/6,2/%,*"2+!)"!0"/3& "Ǿ21+,1,1%ǽ
,2/%,20"%,)! ++,1$"1&#")&+"#/,**,/"1%+,+"-%,+",/&+1"/+"1 ,*-+6ǽ
,2/",+)6)),4"!1,$"1,+"&#")&+""+"Ɯ1-"/%,20"%,)!Ǿnot per personǽ#*,/"1%+,+"-"/0,+&+
6,2/%,20"%,)!$"10&#")&+"Ǿ6,2/"/"(&+$1%" ȉ0/2)"0+!4&))),0"6,2/"+"Ɯ1ǽ

What is a household?
%,20"%,)!&0$/,2-,#-",-)"4%,)&3"1,$"1%"/+!0%/"&+ ,*"+!"5-"+0"0ț"3"+&#1%"6/"
+,1/")1"!1," %,1%"/Ȝǽ,*-)"1"1%"&#")&+"%,20"%,)!4,/(0%""11,!"1"/*&+"&#*,/"1%+,+"
.2)&+$%,20"%,)!&0), 1"!16,2/!!/"00ǽ#*,/"1%+,+"-"/0,+&+6,2/%,20"%,)!-/1& &-1"0&+
&#")&+"Ǿ6,2/"/"(&+$1%" ȉ0/2)"0+!4&))),0"6,2/"+"Ɯ1ǽ

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&#")&+"&0+,+Ȓ1/+0#"/)"ǽ,2 ++,1$&3"6,2/&#")&+""+"Ɯ11,+,1%"/-"/0,+Ǿ"3"+&#1%"6.2)ǽ

Be honest on this form
,2*201$&3" 2/1"+!1/2"&+#,/*1&,+,+1%&0#,/*+!,+))&#")&+"Ȓ/")1"!#,/*0,/
.2"01&,++&/"0ǽ#6,2$&3"#)0",/#/2!2)"+1&+#,/*1&,+Ǿ6,24&))),0"6,2/&#")&+""+"Ɯ1
ț&ǽ"ǽǾ!"Ȓ"+/,))*"+1,/"&+$//"!#/,*1%"-/,$/*Ȝ+!1%"+&1"!11"0$,3"/+*"+1 +1("
)"$) 1&,+0$&+016,2ǽ%&0*6&+ )2!"ț21&0+,1)&*&1"!1,ȜƜ+"0,/&*-/&0,+*"+1ǽ

You may need to show other documents
#1%"&#")&+"/,$/*!*&+&01/1,/&0+,1)"1,3)&!1"1%16,2,/0,*",+"&+6,2/%,20"%,)!.2)
6 %" (&+$3&))"")" 1/,+& /"0,2/ "0ț&+ )2!&+$")&$&&)&16!10"0#,/1%" ȉ0$,3"/+*"+1
$"+ 6-/1+"/0ȜǾ6,2*6+""!1,-/,3&!"!!&1&,+)!, 2*"+10ǽ ,/"5*-)"Ǿ6,2*6+""!1,-/,3&!"
+,ƛ& &)!, 2*"+11%1-/,3"06,2/-/1& &-1&,+&+.2)&+$$,3"/+*"+100&01+ "-/,$/*Ǿ
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--)& 1&,+1,0-""!2--/, "00&+$1&*"ǽ

Recertify
,/" "/1#,/&#")&+""+"Ɯ1ǾƜ)),211%"
required sections of this form, initial every
$/""*"+1011"*"+1Ǿ+!0&$+,+-$"ǚǽ,2
can also recertify online at LifelineSupport.org
#,/#01"01-/, "00&+$ǽ

Page 1 of 7

Mail the form to this address:
USAC
Lifeline Support Center
PO Box 1000
Horseheads, NY 14845

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 0.75
Not yet approved by OMB

FCC FORM 5630

Lifeline Program
Annual Recertification Form

Ǘǽ
Your
Information
All fields are required
unless indicated. Use only
CAPITALIZED LETTERS
and black ink to fill out
this form.

What is your full legal name?
%"+*"6,220",+,ƛ& &)!, 2*"+10Ǿ)&("6,2/, &)" 2/&16/!,/11"ǽ,1+& (+*"ǽ

&/01

&!!)"ț,-1&,+)Ȝ

2ƛ&5ț,-1&,+)Ȝ

Last

What is your phone numberț&#6,2%3",+"Ȝ?

What is your date of birth?

Month

6

Year

What is your email addressț&#6,2%3",+"Ȝ?

What are the last 4 numbers of your Social Security Number (SSN)?
#6,2!,+,1%3"Ǿ4%1&06,2//&)!"+1&Ɯ 1&,+2*"/Ȅ

What is the best way to reach you?
email

-%,+"ȥ

1"51*"00$"ȥ

mail

ȥ#0")" 1"!1%"-%,+",/1"51,-1&,+Ǿ ,+0"+11,)"1 ,+1 1*"1*6&#")&+"-%,+"
+2*"/#,/&*-,/1+1/"*&+!"/0+!2-!1"01,*6&#")&+"0"/3& "ǽ
#0")" 1"!1%"1"51*"00$",-1&,+Ǿ*"00$"+!!1/1"0*6--)6ǽ
"511,"+!*"00$"0ǽ

Page 2 of 7

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 0.75
Not yet approved by OMB

FCC FORM 5630

Lifeline Program
Annual Recertification Form

Ǘǽ
Your
Information
ț ,+1&+2"!Ȝ
ȥ/&))+!0&+ )2!"+6#"!"/))6
/" ,$+&7"!+!&+1/&"ȉ0
/"0"/31&,+Ǿ-2"),Ǿ,/ ,),+6Ǿ
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"01)&0%"!-2/02+11,1%")0(
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,+1"+1ȡ2-),!0ȡ!, 2*"+10ȡ$"1Ȓ
)&#")&+"ȡ# Ț1/&)Ț)+!0Ț*-ǽ-!#

Page 3 of 7

What is your home address?ț%"!!/"004%"/"6,24&))$"10"/3&

"ǽ,+,120"ǽǽ,5Ȝ

1/""12*"/+!*"

-1ǽǾ+&1Ǿ"1 ǽ

11"

&16

&-,!"

Is this a temporary addressȄ

Yes

,

Check if you live on Tribal lands*

What is your mailing address? ț+)6Ɯ))1%&0,21&#&1&0+,11%"0*"06,2/%,*"!!/"00ǽȜ

1/""12*"/+!*"

-1ǽǾ+&1Ǿ"1 ǽ

11"

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&-,!"

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 0.75
Not yet approved by OMB

FCC FORM 5630

Lifeline Program
Annual Recertification Form

ǘǽ
Qualify for
Lifeline
Fill out this section to
show that you, your
dependent, or someone
in your household
qualifies for Lifeline.

Qualify through a government program:
Check all programs that you or someone in your household have:
2--)"*"+1)21/&1&,+00&01+ "/,$/*țȜț ,,!1*-0Ȝ
2--)"*"+1)" 2/&16+ ,*"țȜ
Medicaid
 "!"/)2)& ,20&+$00&01+ "ț Ȝ
"1"/+0"+0&,+,/2/3&3,/0"+"Ɯ1/,$/*0
/&)-" &Ɯ /,$/*0
2/"2,#+!&+ƛ&/0țȜ
"+"/)00&01+ "

You can qualify through
certain government
assistance programs or
through your income (you
do not need to qualify
through both).

/&)"*-,//600&01+ "#,/""!6 *&)&"0ț/&) Ȝ
 ,,!&01/&21&,+/,$/*,++!&+"0"/31&,+0ț Ȝ
/&)"!1/1ț,+)6%,20"%,)!01%1*""11%"&+ ,*".2)&+$01+!/!Ȝ

Or
Qualify through your income:
ț+)6Ɯ))1%&0,21&#6,2!,+,1.2)1%/,2$%$,3"/+*"+1-/,$/*ǽȜ
Including you, how
many people live in your
household? ț %" (,+"Ȝ

Is your income the same or less than the amount listed for your
state and household size?
ț,+)6 %" (6"0,/+,+"511,6,2/%,20"%,)!0&7"Ȝ

))Ǚǝ11"0ǾǾ
+!"//&1,/&"0
ț+,1)0(+!4&&Ȝ

)0(

4&&

1

ʏǗǖǾǚǙǛ

ʏǗǛǾǞǘǘ

ʏǗǙǾǜǝǛ

Yes

,

Ǘ

ʏǗǞǾǗǖǙ

ʏǘǛǾǚǖǝ

ʏǘǘǾǛǕǗ

Yes

,

ǘ

ʏǘǛǾǝǝǗ

ʏǙǛǾǖǕǘ

ʏǙǗǾǙǖǜ

Yes

,

Ǚ

ʏǙǙǾǚǚǕ

ʏǚǚǾǛǝǝ

ʏǚǖǾǗǘǘ

Yes

,

ǚ

ʏǚǗǾǗǖǝ

ʏǛǚǾǗǜǘ

ʏǛǕǾǕǙǝ

Yes

,

Ǜ

ʏǚǞǾǝǝǛ

ʏǜǙǾǝǚǝ

ʏǛǝǾǝǛǙ

Yes

,

ǜ

ʏǛǜǾǚǚǙ

ʏǝǙǾǙǙǘ

ʏǜǜǾǛǜǞ

Yes

,

ǝ

ʏǜǚǾǗǗǗ

ʏǞǙǾǕǗǝ

ʏǝǛǾǙǞǚ

Yes

,

#*,/"1%+ǝǾ!!1%&0
*,2+1#,/" %"51/-"/0,+ǿ

!!ʏǜǾǛǛǝ

!!ʏǞǾǚǝǚ

!!ʏǝǾǝǖǛ

Yes

,

135% of the 2026 Federal Poverty Guidelines
ȥ%" "!"/),3"/16
2&!")&+"0/"16-& ))62-!1"!11%""+!,#
+2/6ǽ

Page 4 of 7

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 0.75
Not yet approved by OMB

FCC FORM 5630

Lifeline Program
Annual Recertification Form

Ǚǽ
$/""*"+1
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

$/""1%1&#*,3"4&))$&3"*60"/3& "-/,3&!"/*6+"4!!/"004&1%&+ǘǕ!60ǽ
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.

ț,/*6!"-"+!"+1,/,1%"/-"/0,+&+*6%,20"%,)!Ȝ 2//"+1)6$"1"+"Ɯ10#/,*1%"$,3"/+*"+1
-/,$/*ț0Ȝ)&01"!,+1%&0#,/*,/*6++2)%,20"%,)!&+ ,*"&0ǖǘǚʢ,/)"001%+1%" "!"/)
,3"/16
2&!")&+"0ț1%"*,2+1)&01"!&+1%" "!"/),3"/16
2&!")&+"01)",+1%&0#,/*Ȝǽ

Initial

Initial

Initial

Initial

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+6*,/"Ǿ&+ )2!&+$ǿ
 ǖȜǾ,/1%"-"/0,+&+*6%,20"%,)!1%1.2)&Ɯ"0Ǿ!,+,1.2)1%/,2$%$,3"/+*"+1
-/,$/*,/&+ ,*"+6*,/"ǽ
ǗȜ&1%"/,/0,*",+"&+*6%,20"%,)!$"10*,/"1%+,+"&#")&+""+"Ɯ1ț&+ )2!&+$*,/"
1%+,+"&#")&+"/,!+!&+1"/+"10"/3& "Ǿ*,/"1%+,+"&#")&+"1")"-%,+"0"/3& "Ǿ,/
,1%&#")&+"1")"-%,+"+!&#")&+"/,!+!&+1"/+"10"/3& "0Ȝǽ
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/"*,3"!#/,*1%"&#")&+"/,$/*+!*6&#")&+""+"Ɯ14&))01,-ǽ
The certification below applies to all consumers and is required to process your application.

Initial

401/21%#2),214%"1%"/,/+,1*/"0&!"+1,#/&))+!0Ǿ0!"Ɯ+"!&+0" 1&,+Ǘ,#1%&0
form.

Signature

Page 5 of 7

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 0.75
Not yet approved by OMB

FCC FORM 5630

Lifeline Program
Annual Recertification Form

ǚǽ
$"+1
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.

Page 6 of 7

What is the agent’s full legal name?
%"+*"6,220",+,ƛ& &)!, 2*"+10Ǿ)&("6,2/, &)" 2/&16/!,/11"ǽ,1+& (+*"ǽ

&/01

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2ƛ&5ț,-1&,+)Ȝ

Last

What is the agent’s Reprersentative ID number?

What is the agent’s date of birth?

Month

6

Year

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

OMB APPROVAL EDITION 3060-0819

FCC FORM 5630

Lifeline Program
Annual Recertification Form
Notice
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1%"&#")&+"-/,$/*ǽ0&+$1%&021%,/&16Ǿ1%" %0!"0&$+1"!01%"-"/*+"+1&#")&+"!*&+&01/1,/ǽ%" %0
-2)&0%"!/2)"0!"1&)&+$%,4 ,+02*"/0 +.2)#,/&#")&+"0"/3& "0+!4%1&#")&+"0"/3& "01%"6*6/" "&3"țǙǜ 
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Purpose: "/" ,))" 1&+$1%&0-"/0,+)&+#,/*1&,+0,4" +3"/1%16,2.2)#,/1%"&#")&+"-/,$/*+!0,4" +
"ƛ& &"+1)6-/,3&!"&#")&+"0"/3& "01,6,2ǽ" "00Ǿ*&+1&++!20"6,2/-"/0,+)&+#,/*1&,+&+1%"*++"/!"0 /&"!
&+1%"&#")&+"601"*,#" ,/!0,1& "țȜǾ ȡȒǖǾ4%& %&03&))"1%11-0ǿȡȡ444ǽ# ǽ$,3ȡ*+$&+$Ȓ!&/" 1,/ȡ
-/&3 61/+0-/"+ 6ȡ-/&3 6Ȓ 1Ȓ&+#,/*1&,+ȱ0601"*0ȡǽ
Routine Uses: "*60%/"1%"-"/0,+)&+#,/*1&,+6,2"+1"/&+1,1%&0#,/*4&1%,1%"/-/1&"0#,/0-" &Ɯ -2/-,0"0Ǿ02 %
0ǿ4&1% ,+1/ 1,/01%1%")-20,-"/1"1%"&#")&+"-/,$/*Ȁ4&1%,1%"/#"!"/)+!011"$,3"/+*"+1$"+ &"01%1%")-
20!"1"/*&+"6,2/&#")&+"")&$&&)&16Ȁ4&1%1%"1")" ,**2+& 1&,+0 ,*-+&"01%1-/,3&!"6,2&#")&+"0"/3& "Ȁ+!4&1%)4
"+#,/ "*"+1+!,1%"/,ƛ& &)0&+3"01&$1&+$-,1"+1&)3&,)1&,+0,#&#")&+"/2)"0ǽ
 ,*-)"1")&01&+$,#1%"4604"*620"6,2/&+#,/*1&,+&0-2)&0%"!&+1%"&#")&+"!"0 /&"!&+1%"Ȋ2/-,0"ȋ
-/$/-%,#1%&0011"*"+1ǽ
Disclosure:,2/"+,1/".2&/"!1,-/,3&!"1%"&+#,/*1&,+4"/"/".2"01&+$Ǿ21&#6,2!,+,1Ǿ6,24&))+,1"")&$&)"1,/" "&3"
&#")&+"0"/3& "02+!"/1%"&#")&+"/,$/*/2)"0ǾǙǜǽ ǽǽȨȨǚǙǽǙǕǕȒǚǙǽǙǗǘǽ

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