View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	FCC Form 497	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 47 CFR 54.400-54.423 47 CFR 54.201-54.207

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Decription of Application Fields			PRA enrollment application fields final 092217.docx		Yes	Yes	Fillable Fileable Signable
Other-Description of Lifeline ETC Reimbursement Data Fields			PRA for NLAD Reimbursement final 092217.docx		Yes	Yes	Fillable Fileable Signable
Other-Description of One-Per-Household Worksheet for Lifeline Program			PRA for universal one-per-household fields final 092217.docx		Yes	Yes	Fillable Fileable Signable
Other-Description of Recertification Form for Lifeline Program			PRA lifeline recertification form fields final 092217.docx		Yes	Yes	Fillable Fileable Signable
Form	FCC 5631	Lifeline Program Household Worksheet	LI_ProposedFCC-WorksheetForm5631-10042017.pdf		Yes	Yes	Fillable Fileable Signable
Form	FCC 5629	Lifeline Program Application Form	LI_ProposedFCC-ApplicationForm5629-10192017-OMB.pdf		Yes	Yes	Fillable Fileable Signable
Form	FCC 5630	Annual Recertification Form	LI_ProposedFCC-RecertificationForm5630-10192017-OMB.pdf		Yes	Yes	Fillable Fileable Signable
Instruction			FCC Form 497 Instructions_Final_7-11-16.docx		Yes	Yes	Fillable Fileable Signable
Form	FCC 497	Description of Services Requested and Certification - Field Descriptions	Lifeline Form 497 Field Descriptions Final-Cean 071216.docx		Yes	Yes	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records
Title: FCC/WCB - 1, Lifeline Program	FR Citation: 82 FR 38686

Number of Respondents: 10,047,179	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	11,977,061	0	0	312,830	0	11,664,231
Annual IC Time Burden (Hours)	5,514,285	0	0	-559,790	0	6,074,075
Annual IC Cost Burden (Dollars)	468,750	0	0	0	0	468,750

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.