Affordable Connectivity Program (ACP) Opt-In Form

Date

Application ID Number

Customer Name

Date of Birth

Address

City

State

Zip Code

Telephone Number

Mobile Number

Email Address

Eligible Qualifying Person within household other than Account Holder and date of birth(DOB):

Name

Last 4 SSN

Date of Birth

Please read and initial each of the following to participate in the ACP Program:

I hereby opt-in to the Affordable Connectivity Program (ACP).

I acknowledge that I am aware of the eligibility requirements for the ACP. If I can't demonstrate eligibility, I will not be enrolled in the program and/or [Company] will be required to de-enroll me from the program.

I acknowledge the ACP is a government program that reduces my broadband internet access service bill.

I acknowledge that I may obtain ACP-supported broadband service from any participating provider of my choosing and that I can transfer my ACP benefit to another provider one time a month.

I acknowledge I may apply the ACP benefit to any broadband service offering of [Company] at the same terms and available to households that are not eligible for the ACP supported service.

I acknowledge my provider may disconnect my ACP supported service after 90 consecutive days of non-payment.

I acknowledge I will be subject to the [Company]'s undiscounted rates and general terms and conditions if the ACP ends, if I transfer my benefit to another provider but continue to receive service from [Company], or upon de-enrollment from the ACP.

I acknowledge I may file a complaint regarding an ACP supported service or any difficulty enrolling with a provider via the Commission's Consumer Complain Center at https://consumercomplaints.fcc.gov/hc/en-us or by calling 888-225-5322.

I acknowledge that the ACP Program is non-transferable and that the discount is limited to one ACP discount per household, and I further certify that no other member of my household is receiving a benefit under the ACP.

I acknowledge that I have reviewed the available services and upload/download speeds and data caps for services offer by [Company] for the ACP Program.

I consent to applying my ACP program benefit to the broadband Internet access service I receive from [Company].

I consent to [Company] disclosing and/or transmitting any information required to the program Administrator for my participation in the program including but not limited to my name, my dependent's name, date of birth, last 4 digits of social security number or Tribal Identification Number, address, telephone number, type of service, start date of service, termination of service date, ACP Program discount amount, eligible program, tribal benefit status, Lifeline Tribal Benefit, Linkup Service Date and Independent Economic Household certification date.

I acknowledge that if [Company] has a reasonable basis to believe that I am no longer eligible to receive the ACP benefit, I will receive a notification of impending termination of my ACP benefit and will have 30 days following the date of such notice to demonstrate continued eligibility.

I acknowledge that my participation in the ACP does not relieve my obligations to adhere to [Company]'s posted rates, terms and conditions, or other rules and regulations or tariffs that govern the services I receive.

I acknowledge that the monthly ACP Benefit will not be prorated but may be less than the full benefit during the first and final month of the program.

I certify that:

I have confirmed my eligibility for the Affordable Connectivity Program through the National Verifier.
I reviewed the above disclosures and consent to ACP program enrollment.

I certify that: (1) I have confirmed my eligibility for the Affordable Connectivity Program through the National Verifier using: (Select One)

Name of School

Are you transferring your ACP benefit from another company to Citizens?

Yes No

Please read and initial each of the following to transfer to Citizens in the ACP Program:

I am transferring my ACP benefit to Citizens.

The effect of the transfer is my ACP benefit will be applied to the Citizens's service and will no longer be applied to service retained from the transfer-out provider.

I may be subject to the transfer-out provider's undiscounted rates because of the transfer if I elect to maintain service from the transfer-out provider.

I am limited to one ACP benefit transfer transaction per service month, with limited exceptions for situations where the subscriber seeks to reverse and unwanted transfer or is unable to receive service from a specific provider.

I acknowledge that I was provided and read the disclosures herein, and that I give my informed consent to transfer my benefit to the transfer-in provider on the date indicated next to my signature.

Submit