Page 4 of 4
Universal Service Administrative Company | www.Get
EmergencyBroadband.org
Need help? Call the Emergency Broadband Support Center at 1-833-511-0311
Notice
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.
Initial
A
6. I live at an address with more than one household.
Initial
B
7. I understand that the one-per-household limit is a Federal Communications Commission
(FCC) rule and I will lose my Emergency Broadband Benefit if I break this rule.
8. Signature
9. Today’s Date
Agreement
Please initial the
agreement below and
sign and date this
worksheet. Submit this
worksheet with your
Emergency Broadband
Benefit Program
Application Form.
I consent to let USAC contact me at the phone
number I provided for important reminders and
updates to my EBB Program service. Message
and data rates may apply. Text STOP to end
messages.
FCC FORM 5639
Emergency Broadband Benefit Program
Household Worksheet
