Lifeline Program - Application Form - FCC Form 5629

Sep 19, 2026

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Lifeline Program Application Form (FCC Form 5629) explains eligibility rules and required household information for receiving a monthly phone or internet service discount. The form defines a household, clarifies limits such as one benefit per household and no transfer to others, and instructs applicants to provide accurate information to avoid loss of benefits and possible legal action. It also describes potential support under the Safe Connections Act for survivors and outlines document proof requirements and submission options by mail or online.

LanguageEnglish

CategoryForms

FormatPDF

Pages8

Reading Time3 min

AccessFree to download

1. About Lifeline

Rules

What is a household?

Do not give your benefit to another person

Be honest on this form

You may need to show other documents

2a. Your Information

Safe Connections Act (SCA)

2b. Your Information (continued)

Approval Edition: February 2026 OMB 3060-0819 Est. time per response: 45 minutes FCC FORM 5629 Lifeline Program Application Form 1. About Lifeline Lifeline is a Federal Communications Commission (FCC) program that provides a monthly phone or internet service discount for qualifying low-income consumers. Rules If you qualify, your household can receive a monthly Lifeline benefit of up to $9.25 to lower the costs of phone or internet service and up to $34.25 for qualifying households on Tribal lands. • If you get Lifeline for phone service, you can get the benefit for one mobile phone or one home 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. • If you get Lifeline for bundled phone and internet service, you can get the benefit for your mobile phone bundled service or your home bundled service, but not both. 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. 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) . Complete the Lifeline household worksheet to determine if more than one qualifying household is located at your address. If more than one person in your household participates in Lifeline, you are breaking the FCC’s rules and will lose your benefit. 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 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. Please include copies of your proof documentation when you submit your application to speed up processing time. | Apply
To apply for a Lifeline benefit, fill out the required sections of this form, initial every agreement statement, and sign on page 6. You can also apply [online at](online at LifelineSupport.org)[ LifelineSupport.org](online at LifelineSupport.org) for fastest processing. | Mail the form to this address:
USAC
Lifeline Support Center PO Box 1000
Horseheads, NY 14845 | | --- | --- | Page 1 of 8 [Universal Service Administrative Company |](Universal Service Administrative Company | www.lifelinesupport.org)[ www.lifelinesupport.org](Universal Service Administrative Company | www.lifelinesupport.org) Need help? Call the Lifeline Support Center at 1-800-234-9473 Approval Edition: February 2026 OMB 3060-0819 Est. time per response: 45 minutes FCC FORM 5629 Lifeline Program Application Form 2a. Your Information All fields are required unless indicated. Use only CAPITALIZED LETTERS and black ink to fill out this form. *The Safe Connections Act (SCA) was enacted to ensure that survivors can separate from abusers without losing independent access to their mobile service. Through the SCA, survivors can receive a 6-month benefit by providing proof of a legitimate line separation request submitted to a service provider and confirming that they are experiencing financial hardship. A survi

FAQs

What is Lifeline and what benefits can eligible households receive?

Lifeline is an FCC program providing a monthly phone or internet service discount for qualifying low-income consumers. Eligible households can receive up to $9.25 monthly, and up to $34.25 for qualifying households on Tribal lands.

How does the form define a household for Lifeline eligibility?

A household is a group of people who live together and share income and expenses, even if they are not related. The applicant must complete the Lifeline household worksheet to determine whether more than one qualifying household is located at the address.

What happens if an applicant provides false or inaccurate information?

Applicants must provide accurate and true information. False or fraudulent information can result in losing the Lifeline benefit, including de-enrollment or being barred from the program, and the U.S. government may take legal actions such as fines or imprisonment.

Sep 19, 2026

Upload by Graffin