Service providers are required to use FCC Forms 5629 (application & certification form), 5630 (annual recertification form), and 5631 (one-per-household worksheet) to confirm subscriber eligibility for the federal Lifeline program. Learn more about these forms in the FCC's Public Notice DA 18-161.
The forms are available in English and Spanish on the Lifeline Program Forms page.
Service providers in all states and territories must begin using the universal forms for initial eligibility verification by July 1, 2018.
For annual recertification, service providers must use these forms for subscribers whose 60-day response period begins on July 1, 2018 or later.
Service providers have the option to begin using the forms immediately. As always, keep copies of the completed forms in your records for the required record retention period.
Service providers are permitted to make the following modifications to the forms:
The following modifications are not permitted:
Service providers in National Verifier states (CO, MS, MT, NM, UT, and WY) should use the National Verifier versions of the forms, which show the Lifeline Support Center's London, KY address on the cover page. Learn more on the National Verifier page.
If state law or regulations require Lifeline service providers to use a pre-existing universal enrollment or recertification form, service providers can continue using those forms rather than FCC Forms 5629, 5630, and 5631. We are in touch with state Lifeline administrators and will update this page as more information becomes available.