A. Either I or someone in my household currently benefits from the government programs indicated on this form, or our household income does not exceed 200% of the Federal Poverty Guidelines as shown in the table provided.
B. Should I relocate, I commit to notifying my service provider of my new address within 30 days.
C. I recognize the necessity to inform my service provider within 30 days if I or any qualifying member of my household no longer meet the eligibility requirements for the Affordable Connectivity Program (ACP). This includes:
- No longer qualifying through a government program or based on household income.
- Receiving more than one ACP benefit within my household.
D. I am aware that only one ACP benefit per household is allowed and to my best knowledge, we are not exceeding this limit. This includes the entitlement to just one connected device (desktop, laptop, or tablet) through the ACP, regardless of changes in providers.
E. I consent to the collection, use, sharing, and retention of the information I submit on this form for the purpose of applying for or receiving the ACP benefit. Should it be required by law, I permit state or Tribal government to share details of my program benefits with the ACP Administrator to verify my eligibility.
F. I acknowledge and accept that the ACP is a federal subsidy aimed at reducing the cost of my broadband internet service, and after the program ends, if we continue the service, standard rates from the provider will apply.
G. I affirm that all information and agreements stated in this form are accurate to the best of my knowledge.
H. I understand that providing false or fraudulent information to receive ACP benefits is a criminal offense and may lead to penalties including fines, imprisonment, de-enrollment from the program, or a ban on future participation.
I. I confirm the accuracy of my residency status on Tribal lands as specified in the “Your Information” section of this form.