Affordable Connectivity Program Application Form
Page 1 of 8Rules If you qualify, your household can receive a monthly Affordable Connectivity Program (ACP) benefit of up to $30 to cover the cost of your internet service and up to $75 for qualifying households on Tribal lands.Through the program, your internet company may also offer a one-time internet connected device benefit of up to $100 for a computer, tablet, or laptop with a co-payment of more than $10 but less than $50.Your household cannot get the ACP benefit from more than one company.You are only allowed to get one ACP benefit per household, not per person.The Affordable Connectivity Program is separate from the FCC’s Lifeline Program.If your household qualifies for both programs, you can apply for and receive both benefits.Note: Internet companies must also meet certain criteria to participate in the AC P.Check with your c ompany to determine if it participates.What is a household? A household is a group of people who live together and share income and expenses (even if they are not related to each other).Complete the ACP household worksheet to determine if more than one qualifying household is located at your address.
If more than one person in your household participates in the AC P, you are breaking the FCC’s rules and will lose your benefit.Do not give your benefit to another person The ACP benefit is non-transferable.You cannot give your benefit to another person, even if they qualify for the AC P.Be honest on this form You must give accurate and true information on this form and on all ACP related forms or questionnaires.If y ou give false or fraudulent information, you will lose your benefit (i.e., de-enro llment or being barred from the pr ogram) and the United States government can take legal action against you.Th is may include (but is n ot limited to) fines or im prisonment.You may need to show other documents If the ACP Administrator is not able to validate that you or someone in your household qualify by checking available electronic resources (including eligibility databases for the FCC’s government agency partners), you may need to provide additional documents.For example, you may need to provide an o fficial document that proves your participation in a qualifying government assistance program, your income, or your identity.
Transcription of Affordable Connectivity Program Application Form
1Please include copies of your proof documentation when you submit your application to speed up processing time.Apply To apply for the ACP, fill out the required sections of this form, initial every agreement statement, and sign on page 7.You can also apply online at AffordableConnectivity.gov for fastest processing.Mail the form to this address: U SAC ACP Support Center P .O.Box 9100 Wilkes-Barre, PA 18773 About the ACP The ACP is a Federal Communications Commission (FCC) program that provides a monthly internet service discount and a one-time connected device benefit from participating internet companies for qualifying low- income consumers.Universal Service Administrative Company | www.AffordableConnectivity.gov Need help? Call the ACP Support Center at 1-8 77-38 4-2575 FCC FORM 5645 Aordable Connectivity Program Application Form Page 2 of 8 1.
2What is your full legal name?The name you use on official documents, like y our Social Security Card or State ID.Not a nickname.2.What is your phone number (if you have one) ? First Your Information All fields are required unless indicated.Use only CAPITALIZED LETTERS and black ink to fill out this form.3.What is your date of birth? Month Day Year 4.What is your email address? (Recommended) 5.Identity Verification.Please select one of the following: a .
3If you would like to verify y our identity using your Social Security number, p lease e nter the la st four digits of your Soci al Security number (SSN4)* Middle (optional) Suffix (optional) Last *Social Security numbers are not required to participate in the Affordable Connectivity Program, but providing a Social Security number will process your application the fastest.b.If you have and would lik e to use a Tribal Identification number to verify your identity, please enter it below .c .Driver’s License, Military ID, Passport, Taxpayer I d entification Number (ITIN), or other Government ID.Please select the type of identification you would like t o us e to verify your identity.Driver’s License Military ID Passport Taxpayer Identification Number Other Government ID Please include a scanned copy or photo of your form of identification with your application.Universal Service Administrative Company | www.AffordableConnectivity.gov Need help? Call the ACP Support Center at 1-877-384-2575 FCC FORM 5645 Affordable Connectivity Program Application Form Page 3 of 8Your I nformation ( c ontinued) * Tribal lands include any federally recognized Indian tribe’s reservation, Pueblo, or colony, including former reservations in Oklahoma; Alaska Native regions established pursuant to the Alaska Native Claims Settlement Act (85 Stat.
4688) ; Indian allotments; Hawaiian Home Lands— areas held in trust for Native Hawaiians by the state of Hawaii, pursuant to the Hawaiian Homes Commission Act, 1920 July 9, 1921, 42 Stat.108, et.seq., as amended; and any land designated as such by the FCC pursuant to the designation process in the FCC’s Lifeline rules.A map of qualifying Tribal lands is available) on USAC’s website: https:// www.affordableconnectivity.gov/wp- content/uploads/acp/ documents/ fcc_tribal_lands_map.pdf 6.What is your home address? (The address where you will get service.Do not use a P.
5O.Box) Street Number and Name City Zip Code State Apt., Unit, etc.7.Is this a temporary address? Yes No 8.Check if you liv e on Tribal lands* 9.What is your mailing address? (Only fill this out if it is not the same as your home address.) Street Number and Name City Zip Code State Apt., Unit, etc.Universal Service Administrative Company | www.
6AffordableConnectivity.gov Need help? Call the ACP Support Center at 1-8 77 -38 4-2575 FCC FORM 5645 Affordable Connectivity Program Application Form Page 4 of 8 Your Information (continued) 10.Check if you ar e qualifying through a child or dependent in your household.If so, answer the following questions: 11.What is their full legal name? Only fill this section out if you are applying through a child or dependent.First 12.What is their date of birth? Month Day Year Middle (optional) Suffix (optional) Last 13.Identity Verification.Please select one of the following: a.If you w ould like to verify your identity using your Social Security number, please enter the last f our digits of your Social Security number (SSN)* *Social Security numbers are not required to participate in the Affordable Connectivity Program, but providing a Social Security number will process your application the fastest.
7b.If you hav e and would like to use a Tribal Identification number to verify your identity please ent er it below.c .Driver’s License, Mili tary ID, Passport, Taxpayer Ident ification Number (ITIN) , or other Government ID.Please sele ct the type of identification you would like to use to verif y your identity.Dri ver’s License M ilitary ID Passport Taxpayer Identification Nu mber O ther Government ID Please include a scanned copy or photo of your form of identification with your application.Universal Service Administrative Company | www.AffordableConnectivity.gov Need help? Call the ACP Support Center at 1-8 77-38 4-2575 FCC FORM 5645 Affordable Connectivity Program Application Form Page 5 of 8 Qualify for the ACP Fill out this section to show that you, your dependent, or someone in your household qualifies for the ACP.You can qualify through certain government assistance programs or through your income (you do not need to qualify through both).
8When you mail this form, please include documents that show you participate in one of the programs you selected or that you qualify through your income.A list of acceptable documents is available at AffordableConnectivity.gov.Qualify through a government program: Or 14.Check all programs that you or someone in your household have: Supplemental Nutrition Assistance Program (SNAP, also called Food Stamps) Supplemental Security Income (SSI) Medicaid F ederal Public Housing Assistance (FPHA) Housing Choic e Voucher (HCV) Program (Section 8 Vouchers) Pr oject-Based Rental Assistance (PBRA)/202/811 Public Housing A ffordable Housing Programs for American Indians, Alaska Natives or Native Hawaiians Veterans Pension or Survivors Benefit Programs Federal Pell Grant for the current award year Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Free and Reduced-Price School Lunch or Breakfast Program, or enrollment in a Community Eligibility Provision School.If you choose this program, please enter your school name, school district and state.School Name School Dis trictState Tribal Specific Programs Bur eau of Indian Affairs (BIA) General Assistance T ribal Temporary Assistance for Needy Families (Tribal TANF) F ood Distribution Program on Indian Reservations (FDPIR) T ribal Head Start (only households that meet the income qualifying standard) Universal Service Administrative Company | www.AffordableConnectivity.gov Need help? Call the ACP Support Center at 1-8 77-38 4-2575 FCC FORM 5645 Affordable Connectivity Program Application Form Page 6 of 8 Qualify for the ACP (continued) Qualify through your income: 15.Including you, how many people live in your household? (check one) 16.
9Is your income the same or less than the amount listed for your state and household size? (only check yes or no next to your household size)All 48 States, DC, and Territories Alaska Hawaii 1 $29,160 $36,420 $33,540 Yes No 2 $39,440 $49,280 $45,360 Yes No 3 $49,720 $62,140 $57,180 Yes No 4 $60,000 $75,000 $69,000 Yes No 5 $70,280 $87,860 $80,820 Yes No 6 $80,560 $100,720 $92,640 Yes No 7 $90,840 $113,580 $104,460 Yes No 8 $101,120 $126,440 $116,280 Yes No If more than 8, add this amount for each extra person: Add $10,280 Add $12,860 Add $11,820 Yes No 200% of the 2023 Federal Poverty Guidelines *The Federal Poverty Guidelines are typically updated at the end of January.Universal Service Administrative Company | www.AffordableConnectivity.gov Need help? Call the ACP Support Center at 1-8 77-38 4-2575 FCC FORM 5645 Affordable Connectivity Program Application Form Page 7 of 8 27.Signature28.T oday’s Date Agreement I agree, under penalty of perjury, to the following statements: You must initial next to each statement.If you fail to initial each statement, your application will be considered incomplete.By providing a phone number, you consent to letting USAC contact you at that phone number via artificial or prerecorded voice message or text for important reminders and updates about your ACP benefit.For text messages, message and data rates may apply.Text STOP to end messages.
10Initial 17.I (or my dependent or o ther person in my household) currently get benefits from the government program(s) listed on this form or 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).Initial 18.I agr ee that if I move I will give my service provider my new address within 30 days.Initial 1 9.I understand that I have to tell my service provider within 30 days if I do not qualify for the ACP anymore, including: 1) I, or the per son in my household that qualifies, do not qualify through a government program or income anymore.2) Either I or someone in my household g ets more than one ACP benefit.Initial 20.I kno w 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 (desktop, laptop, or tablet) through the ACP, even if I switch ACP companies.
11Initial 2 1.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.Initial 22.F or my household, I affirm and understand that the ACP is a 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 company’s undiscounted general rates, terms, and conditions if my household continues to subscribe to the service.Initial 23.All the answ ers and agreements that I provided on this form are true and correct to the best of my knowledge.Initial 2 4.
12I know that willingly giving false or fraudulent information to get ACP benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program.Initial 2 5.The ACP Administrator or my service provider may have to check whether I still qualify at any time.If I need to recertify my ACP benefit, I understand that I have to respond by the deadline or I will be removed from the Affordable Connectivity Program and my ACP benefit will stop.The c ertification below applies to all consumers and is required to process your application.Initial 26.I w as truthful about whether or not I am a resident of Tribal lands, as defined in the “Your Information” section of this form.Universal Service Administrative Company | www.AffordableConnectivity.gov Need help? Call the ACP Support Center at 1-8 77-38 4-2575 FCC FORM 5645 Affordable Connectivity Program Application Form Page 8 of 8 Representative Information Representatives who help consumers apply (such as internet company agents, state and Tribal partners, etc.
13) are required to register in the Representative Accountability Database (RAD) and must enter their Representative ID here.29.What is your Representative ID? How Does the ACP Protect Consumers? The rules protect Affordable Connectivity Program recipients by: • Empowering consumers to choose the service plan that best meets their needs (including a plan they may already be on); • Ensuring consumers have access to supported internet services regardless of their credit status; • Prohibiting companies from excluding consumers with past due balances or prior debt from enrolling in the program; • Preventing consumers from being forced into more expensive or lower quality plans in order to receive the ACP; • Reducing the potential for bill shock or other financial harms; • Allowing ACP recipients to switch companies or internet service offerings; and • Providing a dedicated FCC process for ACP complaints at https://consumercomplaints.fcc.gov.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.
14§254; 47 U.S.C.§1752; 47 CFR Part 54, Subparts E and R.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 Affordable Connectivity Program.We access, maintain and use your personal information in the manner described in the Lifeline System of Records Notice (SORN), FCC/WCB-1, and the Affordable Connectivity Program SORN, formerly known as the Emergency Broadband Benefit Program SORN, FCC/WCB-3, both available at https://www.fcc.gov/managing-director/privacy- transparency/ privacy-act-information#systems/.Routine Uses: We may share the personal information you enter into this form with other parties for specific purposes, such as: • With c ontractors 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 Affordable Connectivity Program; • With o ther 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 Affordable Connectivity Program; • With the t elecommunications 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 Affordable Connectivity Program; • With o ther federal agencies or to other administrative or adjudicative bodies before which the FCC is authorized to appear; • With appr opriate 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 Affordable Connectivity Program SORN (formerly known as the Emergency Broadband Benefit Program SORN) described in the “Purpose” paragraph of this statement.
15Disclosure: 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 Affordable Connectivity Program rules, 47 C.F.R.Part 54, Subpart R.Universal Service Administrative Company | www.AffordableConnectivity.gov Need help? Call the ACP Support Center at 1-8 77-38 4-2575 FCC FORM 5645 Aordable Connectivity Program Application Form.
Affordable Connectivity Program Application Form PDF information
- PDF Name: Affordable Connectivity Program Application Form
- PDF URL: https://www.affordableconnectivity.gov/wp-content/uploads/ACP-Application-Form-English.pdf
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