Application

This household is on qualifying tribal land.

Medicaid
SNAP (Food Stamps)
SSI (Supplemental Security Income)
Veterans Pension or Survivor Benefits
WIC (Women Infants Children)
Section 8
Pell Grant
School Breakfast/School Lunch Program
Federal Public Housing Assistance
Income Qualifications

For those individuals who are not on any of the approved Govt. Benefits Programs, you may apply for a FREE Smartphone or Tablet under the Income Qualifications rule if your can show proof of the following;                                                                                                     

• Your (or your dependent’s) first and last name
• Your annual income
• To show documentation of income that does not cover a full year, such as current pay stubs, the documentation must cover three months in a row within the past twelve months

Document Examples:

• Prior year’s state, federal, or Tribal tax return
• Current income statement from your employer or a paycheck stub
• A Social Security statement of benefits
• Veterans Administration statement of benefits
• Unemployment or Worker’s Compensation statement of benefits
• Divorce decree, child support award, or a similar official document showing your income
• A retirement/pension statement of benefits
• Your (or your dependent’s) first and last name
• Your annual income
• To show documentation of income that does not cover a full year, such as current pay stubs, the documentation must cover three months in a row within the past twelve months

Here are the ways your household can qualify for the Affordable Connectivity Program (ACP):

• Based on your household income
• If you or your child or dependent participate in certain government assistance programs such as SNAP, Medicaid, WIC, or other programs
• If you or anyone in your household already receives a Lifeline benefit

Note: You may qualify for the ACP through a participating provider’s existing low-income program. Visit our How to Apply page to learn more.

My annual household income is 200% or less than the Federal Poverty Guidelines (the amount listed in the Federal Poverty Guidelines table on this form). Must check if applying on Income Qualifications only.

If you have any questions concerning Income Qualifications in applying for The Affordable Connectivity or Life Lifeline Program with contact our Customer Service at (386) 601-4391 and we will answer all of your questions.

I am older than 18 years old.

I am the authorized person to make decisions for Internet services and to change the Internet Service Provider.

I give The ACP&Lifeline Experts the exclusive authority to select on my behalf the Wireless Broadband Service Provider of my choosing and has my permission to retain exclusive authority to select the appropriate Service Provider, Wireless or Data Plan, Equipment, and will act as my personal representative and fiduciary in respects to all decisions concerning my enrollment or transfer in the Affordable Connectivity Program and Lifeline Program.

I'm going to go over the required information to participate in the Affordable Connectivity Program. Answering affirmatively is required in order to enroll in the Affordable Connectivity Program in my state. This authorization is only for the purpose of verifying my participation in this program and will not be used for any purpose other than the Affordable Connectivity Program (ACP).

I am authorizing the Company, The ACP&Lifeline Experts to access any records required to verify my statements on this form and to confirm my eligibility for the Affordable Connectivity Program or Lifeline Program and share this information with the Provider of my wireless, broadband, fiber optic, or satellite Internet services. This will also be applicable to any Telecommunications hardware or equipment such as cell phones, tablets, hotspots, wireless routers or access points, desktop or laptop computers or any accessories that relate to any of the above just mentioned.

For my household, I affirm and understand that the ACP 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.

I agree that if I move I will provide my new address to my service provider within 30 days.

I understand that I have to tell my service provider within 30 days if I do not qualify for ACP benefits anymore, including I, or the person in my household that qualifies, do not qualify through a government program or income anymore.

No one else is getting Affordable Connectivity Program benefits at my house right now.

I know that my household can only get one ACP benefit and, to the best of my knowledge, my household is not getting more than one ACP benefit. I understand that I can only receive one connected device (Tablet) through the ACP benefit, even if I switch ACP providers.

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 ACP benefit. I understand that if this information is not provided to the Program Administrator, I will not be able to get ACP 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 ACP Administrator. The information shared by the state or Tribal government will be used only to help find out if I can get an ACP benefit.

I agree that The ACP&Lifeline Experts can contact me at any time to follow up on my subscription and future service offerings. I understand and agree to the terms and conditions of the ACP program. If I am enrolled ot transferred by anyone other entity, The ACP&Lifeline Experts has my permission to transfer my services to whichever carrier they deem appropriate at that time even if it's a different carrier than the one previous as my new ACP/Lifeline Service Provider. All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.

I hereby certify that I have read this thoroughly and agreed to these disclosures.

I understand that agreeing to these terms and submitting this form is the equivalent of a legal signature.