FCC Form 497

FCC Form 497 OMB Approval

May 2016 Edition 3060-0819

Lifeline/Low Income Universal Service

Description of Services Requested and Certification Form 497

(Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual representation of what each applicant will see).

Item Number	Field Description	Purpose/Instructions
	Service Provider Identification Number	User must provide the nine-digit Service Provider Identification Number (SPIN) for which the certification is being filed. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
	Study Area Code (SAC)	This is the unique USAC identifier for the ETC submitting the filing. Each ETC must provide a separate FCC Form 497 for each SAC used to provide Lifeline service.
	Company Legal Name	User must provide company's legal name.
	Contact Name	User must provide information for the individual who should be contacted with questions about this form.
	Mailing Address	User must provide mailing information for the individual who should be contacted with questions about this form.
	Telephone Number	User must provide the telephone number for the individual who should be contacted with questions about this form.
	Fax Number	User must provide the fax number where the contact person can receive faxes regarding the form.
	Email Address	User must provide the email address for the individual who should be contacted with questions about this form.
	Submission Date	User must provide the date form was submitted. This information will pre-populate.
	Data Month	User must provide the month for which data is being reported, using one worksheet per month.
	Filing Type	User must indicate whether filing is original or a revision of a previous filing.
	State Reporting	User must indicate in which state the ETC is claiming support.
	Line 5a – Number of subscribers receiving voice-only Lifeline service	User must provide the number of Lifeline subscribers receiving Non-Tribal Lifeline federal voice-only support.
	Line 5b – Lifeline voice-only support amount	User must provide the rate per subscriber of Lifeline subscribers receiving Non-Tribal Lifeline federal voice support. This information is pre-populated.
	Line 5c – Total dollar amount for voice-only Lifeline support	User must provide the total dollar amount of Non-Tribal Lifeline federal voice support claimed (multiply Line 5(a) and Line 5(b)). This information is pre-populated based on the user’s previous responses.
	Line 6a – Number of subscribers receiving broadband-only Lifeline service	User must provide the number of Lifeline subscribers receiving Non-Tribal Lifeline federal broadband support.
	Line 6b – Lifeline broadband-only support amount	User must provide the rate per subscriber of Lifeline subscribers receiving Non-Tribal Lifeline federal broadband support. This information is pre-populated.
	Line 6c – Total dollar amount for broadband-only Lifeline support	User must provide the total dollar amount of Non-Tribal Lifeline federal broadband support claimed (multiply Line 6(a) and Line 6(b)). This information is pre-populated based on the user’s previous responses.
	Line 7a – Number of subscribers receiving bundled Lifeline service	User must provide the number of Lifeline subscribers receiving Non-Tribal Lifeline federal bundled support.
	Line 7b – Lifeline bundled support amount	User must provide the rate per subscriber of Lifeline subscribers receiving Non-Tribal Lifeline federal bundled support. This information is pre-populated.
	Line 7c – Total dollar amount for bundled Lifeline support	User must provide the total dollar amount of Non-Tribal Lifeline federal bundled support claimed (multiply Line 7(a) and Line 7(b)). This information is pre-populated based on the user’s previous responses.
	Line 8 – Total dollar amount for all non-Tribal Lifeline support	User must provide the total Non-Tribal Lifeline dollars claimed for the reported month in whole dollars. (Add Lines 5(c), 6(c), and 7(c)). This information is pre-populated based on the user’s previous responses.
	Line 9a – Number of subscribers receiving Tribal voice-only Lifeline service	User must provide the number of Lifeline subscribers receiving Tribal Lifeline federal voice support.
	Line 9b – Tribal Lifeline voice-only support amount	User must provide the rate per subscriber of Lifeline subscribers receiving Tribal Lifeline federal voice support.
	Line 9c – Total dollar amount for Tribal voice-only Lifeline support	User must provide the total dollar amount of Tribal Lifeline federal voice support claimed (multiply Line 9(a) and Line 9(b)). This information is pre-populated based on the user’s previous responses.
	Line 10a – Number of subscribers receiving Tribal broadband-only Lifeline service	User must provide the number of Lifeline subscribers receiving Tribal Lifeline federal broadband support.
	Line 10b – Tribal Lifeline broadband-only support amount	User must provide the rate per subscriber of Lifeline subscribers receiving Tribal Lifeline federal broadband support.
	Line 10c – Total dollar amount for Tribal broadband-only Lifeline support	User must provide the total dollar amount of Tribal Lifeline federal broadband support claimed (multiply Line 10(a) and Line 10(b)). This information is pre-populated based on the user’s previous responses.
	Line 11a – Number of subscribers receiving Tribal bundled Lifeline service	User must provide the number of Lifeline subscribers receiving Tribal Lifeline federal bundled support.
	Line 11b – Tribal Lifeline bundled support amount	User must provide the rate per subscriber of Lifeline subscribers receiving Tribal Lifeline federal bundled support.
	Line 11c – Total dollar amount for Tribal bundled Lifeline support	User must provide the total dollar amount of Tribal Lifeline federal bundled support claimed (multiply Line 11(a) and Line 11(b)). This information is pre-populated based on the user’s previous responses.
	Line 12 – Total dollar amount for all Tribal Lifeline support	User must provide the total Tribal Lifeline federal dollars claimed for the reported month in whole dollars. (Add Lines 9(c), 10(c), and 11(c)). This information is pre-populated based on the user’s previous responses.
	Line 13 – Total dollar amount for all Lifeline support	User must provide the Total Lifeline Support amount to be paid for the reported month. (Add Line 8 and Line 12). This information is pre-populated based on the user’s previous responses.
	Line 14 – Number of subscribers who received Tribal Link Up connection fee waivers	User must provide the number of Link Up subscribers residing on Tribal lands for whom connection charges were waived.
	Line 15 – Average Tribal Link Up connection fee	User must provide the dollar amount of Tribal Link Up claimed per subscriber.
	Line 16 – Total dollar amount for Tribal Link Up connection support	User must provide the dollar amount of Tribal Link Up claimed by multiplying Lines 14 and 15. This information is pre-populated based on the user’s previous responses.
	Line 17 – Total dollar amount for Tribal Link Up support	User must provide the dollar amount of total Link Up support in whole dollars. This information is pre-populated based on the user’s previous responses. This information is pre-populated based on the user’s previous responses.
	Total Lifeline Support	User must provide the dollar amount of total Lifeline support in whole dollars. This information is pre-populated based on the user’s previous responses.
	Total Tribal Link Up	User must provide the dollar amount of total Tribal Link Up support in whole dollars. This information is pre-populated based on the user’s previous responses.
	Total Dollars	User must provide the Total Low-Income Support amount to be paid for the reported month. This information is pre-populated based on the user’s previous responses.
	Line 19 - Certifications and Signatures: I certify that my company will pass through the full amount of all Non-Tribal and Tribal federal Lifeline support for which it seeks reimbursement, as well as all applicable intrastate Lifeline support, to all qualifying low-income subscribers by an equivalent reduction in the subscriber's monthly bill for supported service, or by offering a pre-paid wireless plan that complies with the appropriate minimum service standards contained in 47 CFR §54.408. I certify that my company is in compliance with all of the Lifeline program rules, and, to the extent required, have obtained valid certifications for each subscriber for whom my company seeks reimbursement. Based on the information known to me or provided to me by employees responsible for the preparation of the data being submitted, I certify under penalty of perjury that the data contained in this form has been examined and reviewed and is true, accurate, and complete. I acknowledge the Fund Administrator's authority to request additional supporting information as may be necessary. Persons willfully making false statements on this form can be punished by fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. §1001.	User must certify that an officer of the company has attested to passing the full amount of Lifeline support to qualifying low-income consumers, the company fully complies with applicable rules, and the information contained within the form is true, accurate, and complete.

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