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About Lifeline - cloudfront.net

Examples of one household: • A married couple who live together are one household. They must share one Lifeline benefit. • A parent/guardian and child who ...

About Lifeline

Lifeline HouseholdWorksheet 2019
FCC FORM 5631
Lifeline Program Household Worksheet

OMB APPROVAL EDITION 3060-0819

About Lifeline
Lifeline is a benefit that lowers the monthly cost of phone or internet service (not both). You are only allowed to get one Lifeline benefit per household, not per person.

What this worksheet is for
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.
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).
Examples of one household:
· A married couple who live together are one household. They must share one Lifeline benefit.
· A parent/guardian and child who live together are one household. They must share one Lifeline benefit.
· An 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.
· 30 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.

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

FCC FORM 5631
Lifeline Program Household Worksheet

OMB APPROVAL EDITION 3060-0819

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)

Suffix (optional)

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

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

FCC FORM 5631
Lifeline Program Household Worksheet

OMB APPROVAL EDITION 3060-0819

Can you apply?
Follow this decision tree to confirm if you qualify for the Lifeline Program.

1. Do you live with another adult?
Adults are people who are 18 years old or older, or who are emancipated minors. This can include a spouse, domestic partner, parent, adult son or daughter, adult in your family, adult roommate, etc.

Yes

No

If yes, answer question 2

2. Do they get Lifeline?

Yes

No

If yes, answer question 3

You can apply for Lifeline. You live in a household that does not get Lifeline yet. Please initial line B on page 4, and sign and date the worksheet.
Check this box

3. Do you share money (income and expenses) with them?
This can be the cost of bills, food, etc., and income. If you are married, you should check yes for this question.

Yes

No

You do not qualify for Lifeline because someone in your household already gets the benefit. You are only allowed to get one Lifeline discount per household, not per person.
Check this box

You can apply for Lifeline. Youliveatan address with more than one household and your household does not get Lifeline yet. Please initial lines A and B on page 4, and sign and date the worksheet.
Check this box

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

FCC FORM 5631
Lifeline Program Household Worksheet

OMB APPROVAL EDITION 3060-0819

Agreement
Please initial the agreement below and sign and date this worksheet. Submit this worksheet to your service provider with your Lifeline Program Application Form.

A I live at an address with more than one household.
Initial
B I understand that the one-per-household limit is a Federal Communications Commission (FCC) rule and I will lose my Lifeline benefit if I break this rule.
Initial

Signature

Today's Date

I consent to let USAC contact me at my Lifeline phone number for important reminders and updates to my Lifeline service. Message and data rates may apply. Text STOP to end messages.

Notice
NOTICE: Section 54.410 of the FederalCommunications Commission's rules requires all Lifeline subscribers to demonstratetheir 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 dataprovided in response to this informationcollectionwill be used by USAC to verify the applicant's eligibility for Lifeline services.
We have estimatedthat each response to this collection of information will take, on average, 0.25 hours. Our estimateincludes 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 improvethe collectionandreducetheburdenitcauses you, pleasewritetotheFederalCommunicationsCommission, OMD-PERM, PaperworkReductionProject (3060-0819),Washington,D.C.20554. We also will acceptyour comments viathe Internetif yousend them to PRA@fcc.gov. 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 conductor sponsor this collection,unless it displays a currently validOffice ofManagement 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 informationthat you provide to determineyour 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) theCommission; (b) any employeeof theCommission; or (c) the United Statesgovernment, is a party to a proceeding beforethe 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 AdministrativeCompany (USAC) to explain why we are asking individuals for personal informationand 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 operatethe 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 Lifelineservices toyou. Weaccess,maintainanduse your personal informationin themanner describedin the Lifeline System of Records Notice (SORN), FCC/WCB-1, which we have published in 82 Fed. Reg. 38686 (Aug. 15, 2017).
Routine Uses: Wemay sharethepersonal informationyouenter intothis formwithotherparties for specific purposes,suchas:with contractors that help us operatethe Lifeline program;with other federaland stategovernment agencies that help us determineyour 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.

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


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