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FCC FORM 5638
Emergency Broadband Benefit Program
Application Form
About
the EBB
Program
The EBB Program
is a Federal
Communications
Commission
(FCC) program that
provides a broadband
and/or device benefit
for qualifying low-
income consumers
during the COVID-19
pandemic.
Apply
To apply for the EBB Program, fill out the required
sections of this form, initial every agreement statement,
and sign on page 7. You can also apply online at
GetEmergencyBroadband.org for faster processing.
Mail the form to this address:
USAC
Emergency Broadband Support Center
P.O. Box 7081
London, KY 40742
Universal Service Administrative Company | www.getemergencybroadband.org
Need help? Call the Emergency Broadband Support Center at 1-833-511-0311
Rules
If you qualify, your household can receive a monthly Emergency Broadband Benefit Program (EBB
Program) benefit of up to $50 to cover the cost of your internet service (up to $75 on qualifying Tribal
lands). Through the program, your service provider may also offer a one-time internet connected device
benefit of up to $100 for a computer, tablet, or laptop with a co-payment of more than $10 but less than
$50.
This program is temporary and will expire when the fund runs out of money or six months aer the
Secretary of the Department of Health and Human Services declares an end to the COVID-19 health
emergency.
Your household cannot get the EBB Program benefit from more than one service provider. You are only
allowed to get one EBB Program benefit per household, not per person
. If more than one person in your
household participates in the EBB Program, you are breaking the FCC’s rules and will lose your benefit.
The Emergency Broadband Benefit Program is separate from the FCC's Lifeline Program. If your household
qualifies for both programs, you can apply for and receive both benefits.
Note: Broadband service providers must also meet certain criteria to participate in the EBB Program.
Check with your service provider to determine if it participates.
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
The EBB Program benefit is non-transferable. You cannot give your benefit to another person, even if they
qualify for the EBB Program.
Be honest on this form
You must give accurate and true information on this form and on all EBB Program related forms or
questionnaires. If you give false or fraudulent information, you will lose your benefit (i.e., de-enrollment or
being barred from the program) and the United States government can take legal action against you. This
may include (but is not limited to) fines or imprisonment.
You may need to show other documents
If the EBB 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.
Page 1 of 8
Your
Information
All fields are required
unless indicated. Use only
CAPITALIZED LETTERS
and black ink to fill out
this form.
Universal Service Administrative Company | www.GetEmergencyBroadband.org
Need help? Call the Emergency Broadband Support Center at 1-833-511-0311
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FCC FORM 5638
Emergency Broadband Benefit Program
Application Form
Page 2 of 8
What is your full legal name?
The name you use on official documents, like your Social Security Card or State ID. Not a nickname.
3. What is your date of birth?
Month Day Year
4. What is your email address?
2. What is your phone number (if you have one)?
First
Middle (Optional)
Last
(Recommended)
5. I
dentity Verification. Please select one of the following:
a. If you would like to verify your identity using your Social Security number, please enter the last
four digits of your Social Security number (SSN4)*
*
Social Security numbers are not required to participate in the Emergency Broadband Benefit
Program, but using a Social Security number will process your application the fastest.
b. If you have and would like to use a Tribal Identification Number to verify your identity,
please enter it below.
c. Driver’s License, Military ID, Passport, Taxpayer Identification Number (ITIN), or other
Government ID. Please select the type of identification you would like to use to verify your identity.
Driver’s License
Military ID
Passport
Tax payer Identification Number
Other Government ID
Please include a scanned copy or photo of your form of identification with your application.
Your
Information
(continued)
* Tribal lands include any federally recognized
Indian tribe’s reservation, Pueblo, or colony,
including former reservations in Oklahoma; Alaska
Native regions established pursuant to the Alaska
Native Claims Settlement Act (85 Stat. 688; Indian
allotments; Hawaiian Home Lands—areas held in
trust for Native Hawaiians by the state of Hawaii,
pursuant to the Hawaiian Homes Commission Act,
1920 July 9, 1921, 42 Stat. 108, et. seq., as
amended; and any land designated as such by the
FCC for purposes of this subpart pursuant to the
designation process in the FCC’s Lifeline rules.
A map of qualifying Tribal lands is available on
USAC's website: https://www.usac.org/wp-
content/uploads/lifeline/documents/tribal/
fcc_tribal_lands_map.pdf.
6. What is your home address? (The address where you will get service. Do not use a P.O. Box.)
Street Number and Name
CityApt., Unit, etc.
State
Zip Code
7. Is this a temporary address? Yes
No
8. Check if you live on Tribal lands*
9. What is your mailing address? (Only fill this out if it is not the same as your home address.)
Street Number and Name
City
Zip Code
State
Apt., Unit, etc.
Universal Service Administrative Company | www.GetEmergencyBroadband.org
Need help? Call the Emergency Broadband Support Center at 1-833-511-0311
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FCC FORM 5638
Emergency Broadband Benefit Program
Application Form
Page 3 of 8
Your
Information
(continued)
10. Check if you are qualifying through a child or dependent in your household. If so,
answer the following questions:
11. What is their full legal name?
Only fill this section
out if you are applying
through a child or
dependent.
First
12. What is their date of birth?
Month Day Year
Middle (optional)
Suffix (optional)
Last
Universal Service Administrative Company | www.GetEmergencyBroadband.org
Need help? Call the Emergency Broadband Support Center at 1-833-511-0311
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FCC FORM 5638
Emergency Broadband Benefit Program
Application Form
Page 4 of 8
c. Driver’s License, Military ID, Passport, Taxpayer Identification Number (ITIN), or other
Government ID. Please select the type of identification you would like to use to verify their identity.
Driver’s License
Military ID
Passport
Tax payer Identification Number
Other Government ID
Please include a scanned copy or photo of their form of identification with your application.
*
Social Security numbers are not required to participate in the Emergency Broadband Benefit
Program, but using a Social Security number will process your application the fastest.
b. If you have and would like to use a Tribal Identification Number to verify their identity,
please enter it below.
13. I
dentity Verification. Please select one of the following:
a. If you would like to verify their identity using their Social Security number, please enter the last
four digits of their Social Security number (SSN4)*
14.
Check all programs that you or someone in your household have:
Qualify through a government program or loss of income:
Or
Universal Service Administrative Company | www.getemergencybroadband.org
Need help? Call the Emergency Broadband Support Center at 1-833-511-0311
Bureau of Indian Affairs (BIA) General Assistance
Tribal Temporary Assistance for Needy Families (Tribal TANF)
Food Distribution Program on Indian Reservations (FDPIR)
Tribal Head Start (only households that meet the income qualifying standard)
Tribal Specific Programs
School District
State
School Name
Supplemental Nutrition Assistance Program (SNAP, also called Food Stamps)
Medicaid
Federal Public Housing Assistance (FPHA)
Veterans Pension or Survivors Benefit Programs
Federal Pell Grant for the current award year
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FCC FORM 5638
Emergency Broadband Benefit Program
Application Form
Page 5 of 8
Supplemental Security Income (SSI)
Free and Reduced Price School Lunch or Breakfast Program in the 2019-20 or 2020-21 school
year. If you choose this program, please enter your school name, school district and state.
Qualify for
the EBB
Program
Fill out this section to
show that you, your
dependent, or someone
in your household
qualifies for the EBB
Program.
You can qualify through
certain government
assistance programs or
through your income (you
do not need to qualify
through both).
When you mail this form, please include
documents that show you participate in
one of the programs you selected or that
you qualify through your income. A list
of acceptable documents is available at
GetEmergencyBroadband.org/
Documents
17. Is your income the same or less than the amount listed for
your state and household size?
(
only check yes
or no next to your household size)
All 48 States, DC,
and Territories
Alaska Hawaii
135% of the 2021 Federal Poverty Guidelines
*The Federal Poverty Guidelines are typically updated at the end of January.
16. Including you, how
many people live in your
household? (check one)
Universal Service Administrative Company | www.GetEmergencyBroadband.org
Need help? Call the Emergency Broadband Support Center at 1-833-511-0311
1
$17,388 $21,722 $20,007
Yes No
2
$23,517 $29,390 $27,054
Yes No
3
$29,646 $37,058 $34,101
Yes No
4
$35,775 $44,726 $41,148
Yes No
5
$41,904 $52,394 $48,195
Yes No
6
$48,033 $60,062 $55,242
Yes No
7
$54,162 $67,730 $62,289
Yes No
8
$60,291 $75,398 $69,336
Yes No
If more than 8, add this
amount for each extra person:
Add $6,129 Add $7,668 Add $7,047
Yes No
Qualify through your income:
(continued)
Qualify for
the EBB
Program
Or
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FCC FORM 5638
Emergency Broadband Benefit Program
Application Form
Page 6 of 8
15. Check this box if you or someone in your household experienced a substantial loss of income
due to job loss or furlough aer Februrary 29, 2020 and your 2020 total household income was
the same or less than $99,000 for a single filer or $198,000 for joint filers.
18. I (or my dependent or other person in my household) currently get benefits from the
government program(s) listed on this form, experienced a substantial loss of income since
February 29, 2020, or my annual household income is 135% or less than the Federal Poverty
Guidelines (the amount listed in the Federal Poverty Guidelines table on this form).
19. I agree that if I move I will give my service provider my new address within 30 days.
20. I understand that I have to tell my service provider within 30 days if I do not qualify for the
EBB Program anymore, including:
1.) I, or the person in my household that qualifies, do not qualify through a government
program or income anymore.
2.) Either I or someone in my household gets more than one EBB Program benefit.
21. I know that my household can only get one EBB Program benefit and, to the best of my
knowledge, my household is not getting more than one EBB Program benefit. I understand
that I can only receive one connected device (desktop, laptop, or tablet) through the EBB
Program, even if I switch EBB providers.
22. I agree that all of the information I provide on this form may be collected, used, shared,
and retained for the purposes of applying for and/or receiving the EBB Program benefit. I
understand that if this information is not provided to the Program Administrator, I will not be
able to get EBB Program benefits. If the laws of my state or Tribal government require it, I
agree that the state or Tribal government may share information about my benefits for a
qualifying program with the EBB Program Administrator. The information shared by the state
or Tribal government will be used only to help find out if I can get an EBB Program benefit.
23. For my household, I affirm and understand that the EBB Program is a temporary federal
government subsidy that reduces my broadband internet access service bill and at the
conclusion of the program, my household will be subject to the provider’s undiscounted
general rates, terms, and conditions if my household continues to subscribe to the service.
24. All the answers and agreements that I provided on this form are true and correct to the
best of my knowledge.
25. I know that willingly giving false or fraudulent information to get EBB Program benefits is
punishable by law and can result in fines, jail time, de-enrollment, or being barred from the
program.
26. I was truthful about whether or not I am a resident of Tribal lands, as defined in the "Your
Information" section of this form.
FCC FORM 5638
Emergency Broadband Benefit Program
Application Form
Agreement
I agree, under
penalty of perjury,
to the following
statements:
You must initial next to
each statement.
Universal Service Administrative Company | www.getemergencybroadband.org
Need help? Call the Emergency Broadband Support Center at 1-833-511-0311
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Page 7 of 8
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Representative
Information
Answer only if a Service
Provider Representative
submits this form.
29. What is your Representative ID?
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Administrative Co.
FCC FORM 5638
Emergency Broadband Benefit Program
Application Form
Universal Service Administrative Company | www.GetEmergencyBroadband.org
Need help? Call the Emergency Broadband Support Center at 1-833-511-0311
Page 8 of 8
Privacy Act Statement
This Privacy Act Statement explains how we are going to use the personal information you are entering into this form.
The Privacy Act is a law that requires the Federal Communications Commission (FCC) and the Universal Service Administrative
Company (USAC) to explain why we are asking individuals for personal information and what we are going to do with this
information after we collect it.
Authority: 47 U.S.C. §254; Consolidated Appropriations Act, 2021, Public Law 116–260, div. N, tit. IX, § 904; 47 CFR Part 54,
Subparts E and P.
Purpose: We are collecting this personal information so we can verify your identity and that you qualify for the Lifeline program
or similar programs that use income or consumer participation in certain government benefit programs as eligibility criteria,
such as the Emergency Broadband Benefit Program. We access, maintain and use your personal information in the manner
described in the Lifeline System of Records Notice (SORN), FCC/WCB-1, which was published in 86 Fed. Reg. 11526 (Feb. 25, 2021),
and the Emergency Broadband Benefit Program SORN, FCC/WCB-3, which was published in 86 Fed. Reg. 11523 (Feb. 25, 2021).
Routine Uses: We may share the personal information you enter into this form with other parties for specific purposes, such as:
• With contractors that help us operate the Lifeline program and similar programs that use income or consumer
participation in certain government benefit programs as eligibility criteria, such as the Emergency Broadband Benefit
Program;
• With other federal and state government agencies and Tribal agencies that help us determine your Lifeline eligibility and
eligibility for similar programs that use income or consumer participation in certain government benefit programs as
eligibility criteria, such as the Emergency Broadband Benefit Program;
• With the telecommunications companies and broadband providers that provide you Lifeline service and service under a
similar program that uses income or consumer participation in certain federal benefit programs as eligibility criteria,
such as the Emergency Broadband Benefit Program;
• With other federal agencies or to other administrative or adjudicative bodies before which the FCC is authorized to
appear;
• With appropriate agencies, entities, and persons when the FCC suspects or has confirmed that there has been a breach of
information; and
• With law enforcement and other officials investigating potential violations of Lifeline and other program rules.
A complete listing of the ways we may use your information is published in the Lifeline SORN and the Emergency Broadband
Benefit Program SORN described in the "Purpose" paragraph of this statement.
Disclosure: You are not required to provide the information we are requesting, but if you do not, you will not be eligible to
receive Lifeline services under the Lifeline Program rules, 47 C.F.R. Part 54, Subpart E, or benefits under the Emergency
Broadband Benefit Program, 47 C.F.R. Part 54, Subpart P.
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Completed 12 May 2021

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