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Get FCC Form 5629 2024

FCC FORM 5629 OMB APPROVAL EDITION 3060-0819 Lifeline Program Application Form About Lifeline Lifeline is a federal benefit that lowers the monthly cost of phone or internet service. Rules 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 phone but not both. connection but not both. 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* 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 Security Income SSI benefit letter Federal Public Housing Assistance FPHA award letter or other accepted documents. 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. Page 1 of 8 Apply To apply bring or mail this form to your phone or internet company. To apply for a Lifeline benefit fill out the required sections of this form initial every agreement statement and sign on page 6. Consolidated Communications Consumer Service Response Center P. O. Box 11560 Portland ME 04104 Phone 1. 844. YOUR*CCI 844. 968. 7224 Universal Service Administrative Company www. lifelinesupport. org Need help Call the Lifeline Support Center at 1-800-234-9473 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 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 continued Street Number and Name Apt.

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