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FCC FORM 5629 OMB APPROVAL EDITION 3060-0819
Lifeline Program
Application Form
1. Rules
About If you qualify, your household can get Lifeline for phone or internet service, but not both.
? If you get Lifeline for phone service, you can get the benefit for one mobile phone or one home
phone, but not both.
Lifeline ? If you get Lifeline for internet service, you can get the benefit for your mobile phone or your
Lifeline is a federal home connection, but not both.
benefit that lowers the ? If you get Lifeline for bundled phone and internet service, you can get the benefit for your
monthly cost of phone mobile phone bundled service or your home bundled service, but not both.
or internet service. 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 validate that you or someone in your household qualify
using this form and electronic databases, you may need to provide an official document from one of the
government qualifying programs or documentation that proves 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. If you qualify through a government program, provide a copy of a document such as an approval
letter or benefit letter with the name of the person in your household who qualifies, name of the
program, and issue date within the past 12 months or future expiration date.
2. If you qualify through your income, provide a copy of the prior year's state, federal, or Tribal
tax return or a current income statement from an employer or paycheck stub for 3 consecutive
months (or other accepted documents).
Visit lifelinesupport.org to see all acceptable document guidelines.
Apply Mail the form to this address:
USAC
To apply for a Lifeline benefit, fill out the Lifeline Support Center
required sections of this form, initial every P.O. Box 7081
agreement statement, and sign on page 6. London, KY 40742
Page 1 of 8 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
2a. What is your full legal name?
The name you use on official documents, like your Social Security Card or State ID. Not a nickname.
Your
Information First
All fields are required
unless indicated. Use only Middle (optional) Suffix (optional)
CAPITALIZED LETTERS
and black ink to fill out
this form. 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?
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
FCC FORM 5629 OMB APPROVAL EDITION 3060-0819
Lifeline Program
Application Form
2b. What is your home address? (The address where you will get service. Do not use a P.O. Box)
Your
Information Street Number and Name
(continued) Apt.,Unit,etc. City
State Zip Code
* Tribal lands include any federally recognized Is this a temporary address? Yes No Check if you live on Tribal lands*
Indian tribe's reservation, pueblo, or colony,
including former reservations in Oklahoma;
Alaska Native regions established pursuant to What is your mailing address? (Only fill this out if it is not the same as your home address.)
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, Street Number and Name
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.
Apt., Unit, etc. City
State Zip Code
Page 3 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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