OMB APPROVAL EDITION 3060-0819
Lifeline Program
Application Form
Page 8 of 8 Universal Service Administrative Company | www.lifelinesupport.org
Need help? Call the Lifeline Support Center at 1-800-234-9473
FCC FORM 5629
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 r
esponse to this collection of information will t
ake, on aver
age, between 0.25 and 0.75 hour
s. 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 Oice 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 st
atute or a Commission re
gulation, 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 aer 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
eiciently 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 specic 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 oicials 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.