FCC Form 5629 Lifeline Program Application Form

OMB 3060-0819
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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
#6,2.2)Ǿ6,2/%,20"%,)! +/" "&3"*,+1%)6&#")&+""+"Ɯ1,#2-1,ʏǞǽǗǚ1,),4"/1%" ,010,#
-%,+",/&+1"/+"10"/3& "+!2-1,ʏǘǙǽǗǚ#,/.2)&+$%,20"%,)!0,+/&))+!0ǽ
• If you get Lifeline for phone service, y,2 +$"11%""+"Ɯ1#,/,+"*,&)"-%,+",/,+"%,*"
-%,+"Ǿ21+,1,1%ǽ
• If you get Lifeline for internet service,6,2 +$"11%""+"Ɯ1#,/6,2/*,&)"-%,+",/6,2/%,*"
connection, but not both.
• If you get Lifeline for bundled phone and internet service, 6,2 +$"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 person.

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

o +ot $i3e 6ou/ e+eƜt to a+othe/ -e/so+
&#")&+"&0+,+Ȓ1/+0#"/)"ǽ,2 ++,1$&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/&#")&+""+"Ɯ1ț&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+ "-/,$/*Ǿ6,2/&+ ,*"Ǿ,/
6,2/&!"+1&16ǽ)"0"&+ )2!" ,-&"0,#6,2/-/,,#!, 2*"+11&,+4%"+6,202*&16,2/--)& 1&,+1,
0-""!2--/, "00&+$1&*"ǽ

--ly
,--)6#,/&#")&+""+"Ɯ1ǾƜ)),211%"/".2&/"!
0" 1&,+0,#1%&0#,/*Ǿ&+&1&)"3"/6$/""*"+1
011"*"+1Ǿ+!0&$+,+-$"Ǜǽ,2 +)0,--)6
online at LifelineSupport.org#,/#01"01-/, "00&+$ǽ

Page 1 of 8

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

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FCC FORM 5629

Lifeline Program
Application 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?
ȥ%"#",++" 1&,+0 1țȜ
40"+ 1"!1,"+02/"1%102/3&3,/0
+0"-/1"#/,*20"/04&1%,21
),0&+$&+!"-"+!"+1 "001,1%"&/
*,&)"0"/3& "ǽ%/,2$%1%"Ǿ
02/3&3,/0 +/" "&3"ǛȒ*,+1%
"+"Ɯ16-/,3&!&+$-/,,#,#
)"$&1&*1")&+"0"-/1&,+/".2"01
02*&11"!1,0"/3& "-/,3&!"/
+! ,+Ɯ/*&+$1%11%"6/"
"5-"/&"+ &+$Ɯ++ &)%/!0%&-ǽ
02/3&3,/&0!"Ɯ+"!0+&+!&3&!2)
4%,&0+,1)"001%+ǖǝ6"/0,)!
+!"&1%"/țǖȜ"5-"/&"+ "!!,*"01& 
3&,)"+ "Ǿ!1&+$3&,)"+ "Ǿ0"52)
002)1Ǿ01)(&+$Ǿ0"51/ƛ& (&+$Ǿ
,/țǗȜ /"0#,/0,*",+"4%,
%0"5-"/&"+ "!02 % 10ǽ#
-/1& &-1&+$1%/,2$%1%"Ǿ
consumers can list an address from
1%")01Ǜ*,+1%0ǽ1!,"0+,1%3"
to be your current address.

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

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

-%,+"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 8

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

OMB 3060-0819
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FCC FORM 5629

Lifeline Program
Application Form

Ǘǽ
Your
Information
ț ,+1&+2"!Ȝ
ȥ/&))+!0&+ )2!"+6#"!"/))6
/" ,$+&7"!+!&+1/&"ȉ0
/"0"/31&,+Ǿ-2"),Ǿ,/ ,),+6Ǿ
&+ )2!&+$#,/*"//"0"/31&,+0&+
()%,*Ȁ)0(1&3"/"$&,+0
"01)&0%"!-2/02+11,1%")0(
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țǝǚ11ǽǛǝǝȜȀ+!&+)),1*"+10Ȁ
4&&+,*"+!0ȕ/"0%")!
&+1/201#,/1&3"4&&+061%"
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4-Ȓ ,+1"+1ȡ2-),!0ȡ!, 2*"+10ȡ
$"1Ȓ)&#")&+"ȡ# Ț1/&)Ț)+!0Ț*-ǽ-!#

Page 3 of 8

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

"ǽ,+,120"ǽǽ,5Ȝ

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

-1ǽǾ+&1Ǿ"1 ǽ

11"

City

&-,!"

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"

City

&-,!"

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

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FCC FORM 5629

Lifeline Program
Application Form

Ǘ ǽ
Your
Information
ț ,+1&+2"!Ȝ
Only fill this section
out if you are applying
through a child or
dependent.

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

&/01

&!!)"ț,-1&,+)Ȝ

2ƛ&5ț,-1&,+)Ȝ

Last

What is their date of birth?

Month

6

Year

What are the last 4 numbers of their Social Security Number (SSN)?
#1%"6!,+,1%3"Ǿ4%1&01%"&//&)!"+1&Ɯ 1&,+2*"/Ȅ

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
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FCC FORM 5629

Lifeline Program
Application Form

ǘǽ
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:
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
2/3&3,/0,#,*"01& &,)"+ "1%/,2$%1%"#",++" 1&,+0 1țȜȒmust also complete
Section 5 on page 7
/&)-" &Ɯ /,$/*0
2/"2,#+!&+ƛ&/0țȜ
"+"/)00&01+ "
/&)"*-,//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 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
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FCC FORM 5629

Lifeline Program
Application 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

6-/,3&!&+$-%,+"+2*"/Ǿ
6,2 ,+0"+11,)"11&+$
,+1 16,211%1-%,+"
+2*"/3&/1&Ɯ &),/
-/"/" ,/!"!3,& "*"00$",/
1"51#,/&*-,/1+1/"*&+!"/0
+!2-!1"0,216,2/&#")&+"
"+"Ɯ1ǽ ,/1"51*"00$"0Ǿ
*"00$"+!!1/1"0*6
--)6ǽ"511,"+!*"00$"0ǽ

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

2+!"/01+!1%1%3"1,1"))*60"/3& "-/,3&!"/4&1%&+ǘǕ!60&#!,+,1.2)#,/&#")&+"
+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
(+,41%1*6%,20"%,)! +,+)6$"1,+"&#")&+""+"Ɯ1+!Ǿ1,1%""01,#*6(+,4)"!$"Ǿ
*6%,20"%,)!&0+,1$"11&+$*,/"1%+,+"&#")&+""+"Ɯ1ǽ
$/""1%1)),#1%"&+#,/*1&,+-/,3&!",+1%&0#,/**6" ,))" 1"!Ǿ20"!Ǿ0%/"!Ǿ+!/"1&+"!
#,/1%"-2/-,0"0,#--)6&+$#,/+!ȡ,//" "&3&+$1%"&#")&+"/,$/*"+"Ɯ1ǽ2+!"/01+!1%1
&#1%&0&+#,/*1&,+&0+,1-/,3&!"!1,1%"&#")&+"/,$/*!*&+&01/1,/Ǿ4&))+,1")"1,$"1
&#")&+""+"Ɯ10ǽ#1%")40,#*6011",//&)$,3"/+*"+1/".2&/"&1Ǿ$/""1%11%"011",/
/&)$,3"/+*"+1*60%/"&+#,/*1&,+,21*6"+"Ɯ10#,/.2)&+$-/,$/*4&1%1%"
&#")&+"/,$/*!*&+&01/1,/ǽ%"&+#,/*1&,+0%/"!61%"011",//&)$,3"/+*"+14&))"
20"!,+)61,%")-Ɯ+!,21&# +$"1&#")&+"/,$/*"+"Ɯ1ǽ
))1%"+04"/0+!$/""*"+101%1-/,3&!"!,+1%&0#,/*/"1/2"+! ,//" 11,1%""01
,#*6(+,4)"!$"ǽ
(+,41%14&))&+$)6$&3&+$#)0",/#/2!2)"+1&+#,/*1&,+1,$"1&#")&+"/,$/*"+"Ɯ10&0
-2+&0%)"6)4+! +/"02)1&+Ɯ+"0Ǿ'&)1&*"Ǿ!"Ȓ"+/,))*"+1Ǿ,/"&+$//"!#/,*1%"
-/,$/*ǽ
60"/3& "-/,3&!"/*6%3"1, %" (4%"1%"/01&)).2)1+61&*"ǽ#+""!1,/" "/1
ț/"+"4Ȝ*6&#")&+""+"Ɯ1Ǿ2+!"/01+!1%1%3"1,/"0-,+!61%"!"!)&+",/4&))"
/"*,3"!#/,*1%"&#")&+"/,$/*+!*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,#
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
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FCC FORM 5629

Lifeline Program
Application Form

ǚǽ
2/3&3,/0
,#,*"01&
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:
ț+)6Ɯ))1%&0,21&#6,2.2)02/3&3,/,#,*"01& &,)"+ "Ȝ
Check all programs that you or someone in your household have:
 "!"/)"))
/+1#,/1%" 2//"+14/!6"/
-" &)2--)"*"+1)21/&1&,+/,$/*#,/,*"+Ǿ+#+10Ǿ+!%&)!/"+țȜ
 /""+!"!2 "!Ȓ/& " %,,)2+ %,//"(#01/,$/*Ǿ,/"+/,))*"+1&+,**2+&16)&$&&)&16
/,3&0&,+ %,,)

Or
"/16,2/&+ ,*"6 ,*-)"1&+$1%" %/1"),4ǽ
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

ʏǘǖǾǞǗǕ

ʏǘǞǾǞǕǕ

ʏǘǛǾǜǗǕ

Yes

,

Ǘ

ʏǙǘǾǗǝǕ

ʏǚǙǾǖǕǕ

ʏǙǞǾǜǝǕ

Yes

,

ǘ

ʏǚǙǾǛǙǕ

ʏǛǝǾǘǕǕ

ʏǛǗǾǝǙǕ

Yes

,

Ǚ

ʏǛǛǾǕǕǕ

ʏǝǗǾǚǕǕ

ʏǜǚǾǞǕǕ

Yes

,

ǚ

ʏǜǜǾǘǛǕ

ʏǞǛǾǜǕǕ

ʏǝǝǾǞǛǕ

Yes

,

Ǜ

ʏǝǝǾǜǗǕ

ʏǖǖǕǾǞǕǕ

ʏǖǕǗǾǕǗǕ

Yes

,

ǜ

ʏǖǕǕǾǕǝǕ

ʏǖǗǚǾǖǕǕ

ʏǖǖǚǾǕǝǕ

Yes

,

ǝ

ʏǖǖǖǾǙǙǕ

ʏǖǘǞǾǘǕǕ

ʏǖǗǝǾǖǙǕ

Yes

,

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

!!ʏǖǖǾǘǛǕ

!!ʏǖǙǾǗǕǕ !!ʏǖǘǾǕǛǕ

Yes

,

200% of the 2026 Federal Poverty Guidelines
ȥ%" "!"/),3"/16
2&!")&+"0/"16-& ))62-!1"!11%""+!,#
+2/6ǽ

Initial

Initial

Initial

Page 7 of 8

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OMB APPROVAL EDITION 3060-0819

FCC FORM 5629

Lifeline Program
Application Form

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"-/"0"+11&3"
Information
Representatives who
help consumers apply
(such as phone or internet
company agents, state
and Tribal partners, etc.)
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Notice
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Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473