FCC FORM 5638 Emergency Broadband Benefit Program Application Form About the EBB Program The EBB Program is a Federal Communications Commission
FCC FORM 5638 Emergency Broadband Benefit Program Application Form About the EBB Program The EBB Program is a Federal Communications Commission (FCC) program that provides a broadband and/or device benefit for qualifying lowincome consumers during the COVID-19 pandemic. Rules If you qualify, your household can receive a monthly Emergency Broadband Benefit Program (EBB Program) benefit of up to $50 to cover the cost of your internet service (up to $75 on qualifying Tribal lands). Through the program, your service provider may also offer a one-time internet connected device benefit of up to $100 for a computer, tablet, or laptop with a co-payment of more than $10 but less than $50. This program is temporary and will expire when the fund runs out of money or six months after the Secretary of the Department of Health and Human Services declares an end to the COVID-19 health emergency. Your household cannot get the EBB Program benefit from more than one service provider. You are only allowed to get one EBB Program benefit per household, not per person. If more than one person in your household participates in the EBB Program, you are breaking the FCC's rules and will lose your benefit. The Emergency Broadband Benefit Program is separate from the FCC's Lifeline Program. If your household qualifies for both programs, you can apply for and receive both benefits. Note: Broadband service providers must also meet certain criteria to participate in the EBB Program. Check with your service provider to determine if it participates. 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 The EBB Program benefit is non-transferable. You cannot give your benefit to another person, even if they qualify for the EBB Program. Be honest on this form You must give accurate and true information on this form and on all EBB Program related forms or questionnaires. If you give false or fraudulent information, you will lose your benefit (i.e., de-enrollment or being barred from the program) and the United States government can take legal action against you. This may include (but is not limited to) fines or imprisonment. You may need to show other documents If the EBB Program Administrator is not able to validate that you or someone in your household qualify by checking available electronic resources (including eligibility databases for the FCC's government agency partners), you may need to provide additional documents. For example, you may need to provide an official document that proves your participation in a qualifying government assistance program, your income, or your identity. Apply To apply for the EBB Program, fill out the required sections of this form, initial every agreement statement, and sign on page 7. You can also apply online at GetEmergencyBroadband.org for faster processing. Mail the form to this address: USAC Emergency Broadband Support Center P.O. Box 7081 London, KY 40742 Page 1 of 8 Universal Service Administrative Company | www.getemergencybroadband.org Need help? Call the Emergency Broadband Support Center at 1-833-511-0311 FCC FORM 5638 Emergency Broadband Benefit Program Application Form -·If 1 1 Universal Service Ii Administrative Co. 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? The name you use on official documents, like your Social Security Card or State ID. Not a nickname. First Middle (Optional) Last 2. What is your phone number (if you have one)? 3. What is your date of birth? 4. What is your email address? (Recommended) Month Day Year Page 2 of 8 5. Identity Verification. Please select one of the following: a. If you would like to verify your identity using your Social Security number, please enter the last four digits of your Social Security number (SSN4)* *Social Security numbers are not required to participate in the Emergency Broadband Benefit Program, but using a Social Security number will process your application the fastest. b. If you have and would like to use a Tribal Identification Number to verify your identity, please enter it below. c. Driver's License, Military ID, Passport, Taxpayer Identification Number (ITIN), or other Government ID. Please select the type of identification you would like to use to verify your identity. Driver's License Military ID Passport Tax payer Identification Number Other Government ID Please include a scanned copy or photo of your form of identification with your application. Universal Service Administrative Company | www.GetEmergencyBroadband.org Need help? Call the Emergency Broadband Support Center at 1-833-511-0311 FCC FORM 5638 Emergency Broadband Benefit Program Application Form -·If 1 1 Universal Service Ii Administrative Co. Your Information (continued) 6. 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 e Stat Zip Code *Tribal lands include any federally recognized Indian tribe's reservation, Pueblo, or colony, including former reservations in Oklahoma; Alaska Native regions established pursuant to 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, 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. 7. Is this a temporary address? Yes No 8. Check if you live on Tribal lands* 9. What is your mailing address? (Only fill this out if it is not the same as your home address.) Street Number and Name A map of qualifying Tribal lands is available on Apt., Unit, etc. City USAC's website: https://www.usac.org/wp- content/uploads/lifeline/documents/tribal/ fcc_tribal_lands_map.pdf. State Zip Code Page 3 of 8 Universal Service Administrative Company | www.GetEmergencyBroadband.org Need help? Call the Emergency Broadband Support Center at 1-833-511-0311 FCC FORM 5638 Emergency Broadband Benefit Program Application Form -·If 1 1 Universal Service Ii Administrative Co. Your Information (continued) Only fill this section out if you are applying through a child or dependent. 10. Check if you are qualifying through a child or dependent in your household. If so, answer the following questions: 11. What is their full legal name? First Middle (optional) Suffix (optional) Last 12. What is their date of birth? Month Day Year 13. Identity Verification. Please select one of the following: a. If you would like to verify their identity using their Social Security number, please enter the last four digits of their Social Security number (SSN4)* *Social Security numbers are not required to participate in the Emergency Broadband Benefit Program, but using a Social Security number will process your application the fastest. b. If you have and would like to use a Tribal Identification Number to verify their identity, please enter it below. c. Driver's License, Military ID, Passport, Taxpayer Identification Number (ITIN), or other Government ID. Please select the type of identification you would like to use to verify their identity. Driver's License Military ID Passport Tax payer Identification Number Other Government ID Please include a scanned copy or photo of their form of identification with your application. Page 4 of 8 Universal Service Administrative Company | www.GetEmergencyBroadband.org Need help? Call the Emergency Broadband Support Center at 1-833-511-0311 FCC FORM 5638 Emergency Broadband Benefit Program Application Form -·If 1 1 Universal Service Ii Administrative Co. Qualify for the EBB Program Fill out this section to show that you, your dependent, or someone in your household qualifies for the EBB Program. 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 GetEmergencyBroadband.org/ Documents Qualify through a government program or loss of income: 14. Check all programs that you or someone in your household have: Supplemental Nutrition Assistance Program (SNAP, also called Food Stamps) Supplemental Security Income (SSI) Medicaid Federal Public Housing Assistance (FPHA) Veterans Pension or Survivors Benefit Programs Federal Pell Grant for the current award year Free and Reduced Price School Lunch or Breakfast Program in the 2019-20 or 2020-21 school year. If you choose this program, please enter your school name, school district and state. School Name School District State Tribal Specific Programs Bureau of Indian Affairs (BIA) General Assistance Tribal Temporary Assistance for Needy Families (Tribal TANF) Food Distribution Program on Indian Reservations (FDPIR) Tribal Head Start (only households that meet the income qualifying standard) Or Page 5 of 8 Universal Service Administrative Company | www.getemergencybroadband.org Need help? Call the Emergency Broadband Support Center at 1-833-511-0311 FCC FORM 5638 Emergency Broadband Benefit Program Application Form -·If 1 1 Universal Service Ii Administrative Co. Qualify for Qualify through your income: the EBB Program I 15. Check this box if you or someone in your household experienced a substantial loss of income due to job loss or furlough after Februrary 29, 2020 and your 2020 total household income was the same or less than $99,000 for a single filer or $198,000 for joint filers. I (continued) Or 16. Including you, how many people live in your household? (check one) 17. Is your income the same or less than the amount listed for your state and household size? (only check yes or no next to your household size) All 48 States, DC, and Territories Alaska Hawaii 1 $17,388 $21,722 $20,007 Yes No 2 $23,517 $29,390 $27,054 Yes No 3 $29,646 $37,058 $34,101 Yes No 4 $35,775 $44,726 $41,148 Yes No 5 $41,904 $52,394 $48,195 Yes No 6 $48,033 $60,062 $55,242 Yes No 7 $54,162 $67,730 $62,289 Yes No 8 $60,291 $75,398 $69,336 Yes No If more than 8, add this amount for each extra person: Add $6,129 Add $7,668 Add $7,047 Yes No 135% of the 2021 Federal Poverty Guidelines *The Federal Poverty Guidelines are typically updated at the end of January. Page 6 of 8 Universal Service Administrative Company | www.GetEmergencyBroadband.org Need help? Call the Emergency Broadband Support Center at 1-833-511-0311 FCC FORM 5638 Emergency Broadband Benefit Program Application Form Agreement Initial I agree, under penalty of perjury, to the following statements: Initial You must initial next to each statement. Initial Initial Initial Initial Initial Initial Initial 18. I (or my dependent or other person in my household) currently get benefits from the government program(s) listed on this form, experienced a substantial loss of income since February 29, 2020, or my annual household income is 135% or less than the Federal Poverty Guidelines (the amount listed in the Federal Poverty Guidelines table on this form). 19. I agree that if I move I will give my service provider my new address within 30 days. 20. I understand that I have to tell my service provider within 30 days if I do not qualify for the EBB Program anymore, including: 1.) I, or the person in my household that qualifies, do not qualify through a government program or income anymore. 2.) Either I or someone in my household gets more than one EBB Program benefit. 21. I know that my household can only get one EBB Program benefit and, to the best of my knowledge, my household is not getting more than one EBB Program benefit. I understand that I can only receive one connected device (desktop, laptop, or tablet) through the EBB Program, even if I switch EBB providers. 22. I agree that all of the information I provide on this form may be collected, used, shared, and retained for the purposes of applying for and/or receiving the EBB Program benefit. I understand that if this information is not provided to the Program Administrator, I will not be able to get EBB Program benefits. If the laws of my state or Tribal government require it, I agree that the state or Tribal government may share information about my benefits for a qualifying program with the EBB Program Administrator. The information shared by the state or Tribal government will be used only to help find out if I can get an EBB Program benefit. 23. For my household, I affirm and understand that the EBB Program is a temporary federal government subsidy that reduces my broadband internet access service bill and at the conclusion of the program, my household will be subject to the provider's undiscounted general rates, terms, and conditions if my household continues to subscribe to the service. 24. All the answers and agreements that I provided on this form are true and correct to the best of my knowledge. 25. I know that willingly giving false or fraudulent information to get EBB Program benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program. 26. I was truthful about whether or not I am a resident of Tribal lands, as defined in the "Your Information" section of this form. Page 7 of 8 Universal Service Administrative Company | www.getemergencybroadband.org Need help? Call the Emergency Broadband Support Center at 1-833-511-0311 FCC FORM 5638 Emergency Broadband Benefit Program Application Form -·If 1 1 Universal Service Ii Administrative Co. Representative Information Answer only if a Service Provider Representative submits this form. 29. What is your Representative ID? Privacy Act Statement This Privacy Act Statement explains how we are going to use the personal information you are entering into this form. 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: 47 U.S.C. §254; Consolidated Appropriations Act, 2021, Public Law 116260, div. N, tit. IX, § 904; 47 CFR Part 54, Subparts E and P. Purpose: We are collecting this personal information so we can verify your identity and that you qualify for the Lifeline program or similar programs that use income or consumer participation in certain government benefit programs as eligibility criteria, such as the Emergency Broadband Benefit Program. We access, maintain and use your personal information in the manner described in the Lifeline System of Records Notice (SORN), FCC/WCB-1, which was published in 86 Fed. Reg. 11526 (Feb. 25, 2021), and the Emergency Broadband Benefit Program SORN, FCC/WCB-3, which was published in 86 Fed. Reg. 11523 (Feb. 25, 2021). 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 and similar programs that use income or consumer participation in certain government benefit programs as eligibility criteria, such as the Emergency Broadband Benefit Program; · With other federal and state government agencies and Tribal agencies that help us determine your Lifeline eligibility and eligibility for similar programs that use income or consumer participation in certain government benefit programs as eligibility criteria, such as the Emergency Broadband Benefit Program; · With the telecommunications companies and broadband providers that provide you Lifeline service and service under a similar program that uses income or consumer participation in certain federal benefit programs as eligibility criteria, such as the Emergency Broadband Benefit Program; · With other federal agencies or to other administrative or adjudicative bodies before which the FCC is authorized to appear; · With appropriate agencies, entities, and persons when the FCC suspects or has confirmed that there has been a breach of information; and · With law enforcement and other officials investigating potential violations of Lifeline and other program rules. A complete listing of the ways we may use your information is published in the Lifeline SORN and the Emergency Broadband Benefit Program 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. Part 54, Subpart E, or benefits under the Emergency Broadband Benefit Program, 47 C.F.R. Part 54, Subpart P. Page 8 of 8 Universal Service Administrative Company | www.GetEmergencyBroadband.org Need help? Call the Emergency Broadband Support Center at 1-833-511-0311Adobe InDesign 16.0 (Windows) Acrobat Pro DC 21 Paper Capture Plug-in