About Lifeline: Rules

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
Lifeline
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.
Lifeline is a federal
• If you get Lifeline for bundled phone and internet service, you can get the benefit for your mobile
benefit that lowers the phone bundled service or your home bundled service, but not both.
monthly cost of phone
Your household cannot get Lifeline from more than one phone or internet company.
or internet service.
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

You will need to show your phone or internet company an official document from one of the government
qualifying programs or prove your annual income. Please provide copies of your official documents with this
application. Include the documents in option 1 or option 2 below:
1. If you qualify through a government program: copies of your state ID card and an official document
from the program you are qualifying through (your SNAP card, Medicaid card, Supplemental
Security Income (SSI) benefit letter, Federal Public Housing Assistance (FPHA) award letter, or
other accepted documents).
2. If you qualify through your income: copies of your state ID card and your last state, federal,
or Tribal tax return, pay stubs for 3 consecutive months, or other accepted documents. Visit
lifelinesupport.org to see the full list of accepted documents.
Visit lifelinesupport.org to see the full list of accepted documents.
Apply To apply, bring or mail this form to your phone or

internet company.
To apply for a Lifeline benefit, fill out the required SafeLink Wireless
sections of this form, initial every agreement P.O. Box 220009
statement, and sign on page 6. Milwaukee, OR 97269-0009
Page 1 of 8 Universal Service Administrative Company | www.lifelinesupport.org

Need help? Call the Lifeline Support Center at 1-800-234-9473
Lifeline Program
Application Form
2.
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 First
Information
Middle (optional) Suffix (optional)
All fields are required
unless indicated. Use only
CAPITALIZED LETTERS Last
and black ink to fill out
this form. 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

Lifeline Program
Application Form
2. 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, 1921, Street Number and Name
42 Stat. 108, et. seq., as amended; and any
land designated as such by the Commission
for purposes of this subpart pursuant to the
designation process in the FCC’s Lifeline rules.
Apt., Unit, etc. City
State Zip Code

Lifeline Program
Application Form
2.
Your
heck if you are qualifying through a child or dependent in your household.
C
If so, answer the following questions:
Information
What is their full legal name?
(continued) First
Only fill this section

out if you are applying
through a child or
dependent.
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?

Lifeline Program
Application Form
3. Qualify through a government program:
Qualify for Check all programs that you or someone in your household have:
Lifeline Supplemental Nutrition Assistance Program (SNAP) (Food Stamps)

Supplemental Security Income (SSI)
Fill out this section to Medicaid

show that you, your Federal Public Housing Assistance (FPHA)
dependent, or someone Veterans Pension or Survivors Benefit Programs
in your household
qualifies for Lifeline. Tribal Specific Programs
Bureau of Indian Affairs (BIA) General Assistance
You can qualify through Tribal Temporary Assistance for Needy Families (Tribal TANF)
some government Food Distribution Program on Indian Reservations (FDPIR)
assistance programs or Tribal Head Start (only households that meet the income qualifying standard)
through your income (you
do not need to qualify
through both).
Or
Qualify through your income:
(Only fill this out if you do not qualify through a government program.)
Including you, how Is your income the same or less than the amount listed for your
many people live in your state and household size?
household? (check one) (only check yes or no next to your household size)
All 48 States & DC Alaska Hawaii

(not Alaska and Hawaii)
1 $16,389 $20,493 $18,846 Yes No
2 $22,221 $27,783 $25,555.50 Yes No
3 $28,053 $35,073 $32,265 Yes No
4 $33,885 $42,363 $38,974.50 Yes No
5 $39,717 $49,653 $45,684 Yes No
6 $45,549 $56,943 $52,393.50 Yes No
7 $51,381 $64,233 $59,103 Yes No
8 $57,213 $71,523 $65,812.50 Yes No

If more than 8, add this Add
Add $5,832 Add $7,290 Yes No
amount for each extra person: $6,709.50
135% of the 2018 Federal Poverty Guidelines

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

Lifeline Program
Application Form
4. Initial
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
Agreement
Poverty Guidelines (the amount listed in the Federal Poverty Guidelines table on this form).
I agree that if I move I will give my service provider my new address within 30 days.
I agree, under Initial
penalty of perjury, I understand that I have to tell my service provider within 30 days if I do not qualify for Lifeline
to the following anymore, including:
Initial
1) I, or the person in my household that qualifies, do not qualify through a government
statements:
program or income anymore.
2) Either I or someone in my household gets more than one Lifeline benefit (including, more
You must initial next to than one Lifeline broadband internet service, more than one Lifeline telephone service, or
each statement. 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.
Initial
I agree that my service provider can give the Lifeline Program administrator all of the information I
am giving on this form. I understand that this information is meant to help run the Lifeline Program
Initial
and that if I do not let them give it to the Administrator, I will not be able to get Lifeline benefits.
ll the answers and agreements that I provided on this form are true and correct to the best of
A
my knowledge.
Initial
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
Initial
program.
y service provider may have to check whether I still qualify at any time. If I need to recertify
M
(renew) my Lifeline benefit, I understand that I have to respond by the deadline or I will be
Initial
removed from the Lifeline Program and my Lifeline benefit will stop.
I was truthful about whether or not I am a resident of Tribal lands, as defined in section 2 of this
form.
Initial
I consent to let USAC contact me at my Lifeline

phone number for important reminders and Signature Today’s Date
updates to my Lifeline service. Message and data
rates may apply. Text STOP to end messages.

Lifeline Program
Application Form
5. What is the agent’s full legal name?

Agent
Information
First
Answer only if a sales

person submits this form.
Last
What is the agent’s ID number? What is the agent’s date of birth?
Month Day Year

Lifeline Program
Application Form
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
Commission’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.
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, which we have published in 82 Fed. Reg. 38686 (Aug. 15, 2017).
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.

Lifeline Program
Household Worksheet
About What this worksheet is for

Lifeline Use this worksheet if someone else at your address gets Lifeline. The answers to these questions will
help you find out if there is more than one household at your address.
Lifeline is a benefit that

lowers the monthly cost What is a household?
of phone or internet A household is a group of people who live together and share income and expenses (even if they are
service (not both). You not related to each other).
are only allowed to get
one Lifeline benefit Examples of one household:
per household, not per •A
married couple who live together are one household. They must share one Lifeline
person. benefit.
•A
parent/guardian and child who live together are one household. They must share one
Lifeline benefit.
•A
n adult who lives with friends or family who financially support him/her are one
household. They must share one Lifeline benefit.
Examples of more than one household:

• 4 roommates who live together but do not share money are 4 households. They can have
one Lifeline benefit each, 4 total.
• 3 0 seniors who live in an assisted-living home are 30 households. They can have one
Lifeline benefit each, 30 total.
Household expenses
A household shares expenses. Household expenses include, but are not limited to, food, healthcare
expenses, and the cost of renting or paying a mortgage on your place of residence and utilities.
Income
Households share income. Income includes salary, public assistance benefits, social security
payments, pensions, unemployment compensation, veteran’s benefits, inheritances, alimony, child
support payments, worker’s compensation benefits, gifts, and lottery winnings.

Lifeline Program
Household Worksheet
Your What is your full legal name?

Information First
All fields are required
unless indicated. Use only
CAPITALIZED LETTERS Middle (optional) Suffix (optional)
and black ink to fill out

this form.
Last
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. City
State Zip Code

Lifeline Program
Household Worksheet
Can you 1. Do you live with another adult?

Adults are people who are 18 years old or older, or who are emancipated
apply?
minors. This can include a spouse, domestic partner, parent, adult son or
daughter, adult in your family, adult roommate, etc.
Follow this decision tree Yes No

to confirm if you qualify If yes, answer
question 2
for the Lifeline Program.
You can apply for
Lifeline. You live in a
household that does
not get Lifeline yet.
Please initial line B on
2. Do they get Lifeline? page 4, and sign and
Yes No date the worksheet.
If yes, answer
question 3 Check this box
3. Do you share money (income and expenses)

with them? You can apply for
This can be the cost of bills, food, etc., and income. If you are married,
Lifeline. You live at an
you should check yes for this question.
address with more than
Yes No one household and
your household does
not get Lifeline yet.
Please initial lines
A and B on page 4,
You do not qualify for Lifeline because someone in your household and sign and date the
already gets the benefit. You are only allowed to get one Lifeline worksheet.
discount per household, not per person.
Check this box
Check this box

Lifeline Program
Household Worksheet
Agreement Initial
A I live at an address with more than one household.
Please initial the B I understand that the one-per-household limit is a Federal Communications Commission
agreement below and (FCC) rule and I will lose my Lifeline benefit if I break this rule.
Initial
sign and date this
worksheet. Submit this
Signature Today’s Date
worksheet to your
service provider with
your Lifeline Program
Application Form.
I consent to let USAC contact me at my Lifeline
phone number for important reminders and Notice
updates to my Lifeline service. Message and data
rates may apply. Text STOP to end messages.
NOTICE: Section 54.410 of the Federal Communications Commission’s rules requires all Lifeline subscribers to demonstrate their
eligibility to receive Lifeline services. If more than one person at the same address is applying for Lifeline service, all applicants
must submit a Household Worksheet. This collection of information stems from the Commission’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, 0.25 hours. Our estimate includes the
time to read and complete the form 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 in this
form. We will use the information that you provide to determine your eligibility for Lifeline services. If we believe there may be a
violation or potential violation of a statute or a Commission regulation, rule, or order, your form 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, which we have published in 82 Fed. Reg. 38686 (Aug. 15, 2017).
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.

LIFELINE ASSISTANCE PROGRAM. KENTUCKY CERTIFICATION FORM
PromoCode: Enrollment ID:
Section 1
Your Plan Features
If you qualify for SafeLink Wireless, you can receive a free SafeLink phone, or use your current one with our Keep Your Own Smartphone program. Select which
phone option you would prefer.
Keep Your Own Smartphone Free SafeLink

Phone
350 FREE monthly minutes & unlimited texts. Receive
1.5GB/month of FREE data for the first 3 months of 350 FREE monthly
service and 1GB/month thereafter. OR minutes & unlimited
texts with
You must have a compatible phone or other Unlocked 1GB/month of FREE
GSM phone in order to participate in the SafeLink Keep data.
Your Own Smartphone plan.
*Unused balance will not carryover from month to month.

Only new or returning customers who have been De-enrolled for more than 90 days will receive our Keep Your Own Smartphone promotion.
The Android robot is reproduced or modified from work created and shared by Google and used according to terms and conditions described in the Creative
Commons 3.0 Attribution License.
Section 2
You MUST initial all statements. (Your application cannot be approved without these items.)
I authorize SafeLink Wireless® or its duly appointed representative to: (1) access any records required to verify my statements herein; (2) to confirm my
continued eligibility for Lifeline assistance; (3) to update my address to proper mailing address format; (4) to provide my name, telephone number, and
address to the Universal Service Administrative Company (USAC) (the administrator of the program) and/or its agents for the purpose of verifying that I do
not receive more than one Lifeline benefit; and (5) authorize social service agency representatives to discuss with and/or provide information to SafeLink
Wireless® verifying my participation in benefit programs that qualify me for Lifeline assistance.
This service is supported by LifeLine. Lifeline is a federal benefit that makes monthly telephone and broadband service more affordable for eligible households. Your
household may receive the Lifeline benefit for telephone service OR broadband service, but not both. For Lifeline telephone service, your household may receive the Lifeline
benefit for one mobile OR one fixed home telephone service, but not both. For Lifeline broadband service, your household may receive the Lifeline benefit for one mobile
broadband OR one fixed broadband service, but not both. Your household may not receive the Lifeline benefit from more than one service provider. For the purpose of
Lifeline, a household is an individual or any group of individuals who live together at the same address and share income and expenses. Lifeline is a non-transferable
benefit. You may not transfer your Lifeline benefit to another person, even if he or she is eligible. You will lose your Lifeline benefit and may be prosecuted by the United
States government if you violate the one-per-household rule or otherwise make false statements to receive the Lifeline benefit.

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FCC FORM 5629 OMB APPROVAL EDITION 3060-0819

Do not give your benefit to another person

Be honest on this form

You may need to show other documents

Apply To apply, bring or mail this form to your phone or

Page 1 of 8 Universal Service Administrative Company | www.lifelinesupport.org

Month Day Year

What is your email address (if you have one)?

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

What is the best way to reach you?

Page 2 of 8 Universal Service Administrative Company | www.lifelinesupport.org

(continued) Apt., Unit, etc. City

State Zip Code

State Zip Code

Page 3 of 8 Universal Service Administrative Company | www.lifelinesupport.org

Only fill this section

What is their date of birth?

Month Day Year

If they do not have a SSN, what is their Tribal Identification Number?

Page 4 of 8 Universal Service Administrative Company | www.lifelinesupport.org

3. Qualify through a government program:

Lifeline Supplemental Nutrition Assistance Program (SNAP) (Food Stamps)

Fill out this section to Medicaid

All 48 States & DC Alaska Hawaii

1 $16,389 $20,493 $18,846 Yes No

2 $22,221 $27,783 $25,555.50 Yes No

3 $28,053 $35,073 $32,265 Yes No

4 $33,885 $42,363 $38,974.50 Yes No

5 $39,717 $49,653 $45,684 Yes No

6 $45,549 $56,943 $52,393.50 Yes No

7 $51,381 $64,233 $59,103 Yes No

8 $57,213 $71,523 $65,812.50 Yes No

135% of the 2018 Federal Poverty Guidelines

Page 5 of 8 Universal Service Administrative Company | www.lifelinesupport.org

I consent to let USAC contact me at my Lifeline

Page 6 of 8 Universal Service Administrative Company | www.lifelinesupport.org

5. What is the agent’s full legal name?

Answer only if a sales

What is the agent’s ID number? What is the agent’s date of birth?

Month Day Year

Page 7 of 8 Universal Service Administrative Company | www.lifelinesupport.org

Page 8 of 8 Universal Service Administrative Company | www.lifelinesupport.org

About What this worksheet is for

Lifeline is a benefit that

Examples of more than one household:

Page 1 of 4 Universal Service Administrative Company | www.lifelinesupport.org

Your What is your full legal name?

and black ink to fill out

Street Number and Name

Apt., Unit, etc. City

State Zip Code

Page 2 of 4 Universal Service Administrative Company | www.lifelinesupport.org

Can you 1. Do you live with another adult?

Follow this decision tree Yes No

3. Do you share money (income and expenses)

Page 3 of 4 Universal Service Administrative Company | www.lifelinesupport.org

Page 4 of 4 Universal Service Administrative Company | www.lifelinesupport.org

PromoCode: Enrollment ID:

Keep Your Own Smartphone Free SafeLink

Can you 1. Do you live with another adult?