Lifeline

Forms

Service providers must file online. Click here for Prior Year Forms

Reimbursement Claims

Lifeline Claims System

Reimbursement Claims and Revisions for 2018 data months.

File Online (using E-File credentials)

Submit and certify by the 8th for same-month payment.

LCS User Guide

LCS Upload Validation Rules

Learn more on the Claim Reimbursement page.

FCC Form 497

Reimbursement Claims and Revisions for 2017 data months.

File Online

FCC Form 497

FCC Form 497 (editable)

FCC Form 497 bulk upload

Lifeline Worksheet

Note: Do not use FCC Form 497 for data months in 2018 and later. Instead, use the Lifeline Claims System (available via NLAD).

FCC Form 497 Instructions

FCC Form 497 Online Filing Instructions

Establishing User Entitlements

Annual Filings

FCC Form 481

File Online

Carrier Annual Reporting Data Collection Form
Due July 1

Visit the High Cost Program Forms page for the FCC Form 481 template, instructions, user guide, and more.

FCC Form 555

File Online

FCC Form 555 bulk upload

Annual Lifeline Eligible Telecommunications Carrier Certification Form (Reports Recertification Results)
Due January 31

Hurricane Relief is available for areas impacted by hurricanes Harvey, Irma, and Maria in 2017.

FCC Form 555 Instructions

Learn more on the FCC Form 555 page.

Consumer Forms

Non-National Verifier Forms

*NEW* Required in all states and territories as of
July 1, 2018.

FCC Form 5629: Lifeline Application Form

FCC Form 5630: Annual Recertification Form

FCC Form 5631: Household Worksheet

Spanish language:

FCC Form 5629 (Spanish): Lifeline Application Form

FCC Form 5630 (Spanish): Recertification Form

FCC Form 5631 (Spanish): Household Worksheet

*Note: Spanish forms updated 6/18/2018

Required use began July 1, 2018.

English and Spanish application forms, recertification forms, and household worksheets for service providers to use in all states and territories (non-National Verifier states).

Note: Do not send these forms to the London, KY address. Instead, send these forms to your service provider.

Learn more on the Universal Lifeline Consumer Forms web page.

National Verifier Forms

Official National Verifier Application Form

Official National Verifier Recertification Form

Official National Verifier Household Worksheet

Spanish language:

Official (Spanish) National Verifier Application Form

Official (Spanish) National Verifier Recertification Form

Official (Spanish) National Verifier Household Worksheet

*Note: Spanish forms updated 6/18/2018

Optional use begins upon the National Verifier's soft launch in a state. Required use begins upon hard launch in a state.

English and Spanish paper applications, recertification forms, and household worksheets for use in National Verifier states (CO, MS, MT, NM, UT, WY).

Note: The Lifeline Support Center is accepting paper National Verifier forms from service providers.