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.
Universal Forms Required Beginning July 1, 2018
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.
What You Can Change
Service providers are permitted to make the following modifications to the forms:
- Add your company’s mailing address to the cover page (do not send forms to the Lifeline Support Center in London, KY)
- Additional questions on an attachment, for example, state-required information or billing information
- Companies may build an online version of these forms
- Companies can directly translate the form into languages other than English and Spanish
What Cannot be Modified
The following modifications are not permitted:
- If you are creating an online version of the forms, do not change the language that is used in FCC Forms 5629, 5630, and 5631
- Do not translate the form into Spanish; use the FCC-provided Spanish-language forms
- Do not omit page 1 of the form (this contains required information and disclosures)
- The formal record of certifications must be in the same order as the paper forms
National Verifier and State-Specific Forms
Service providers in National Verifier states 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.