Affordable Connectivity Program (ACP) Opt-In Form

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

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

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

I acknowledge that I am aware of the eligibility requirements for the ACP Program.

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 an Affordable Connectivity Programunder the ACP

I acknowledge that I have reviewed the available upload/download speeds for services offered by Citizens Telephone Cooperative (dba Citizens) for the ACP Program.(See our plans at

I acknowledge that the ACP Program is a temporary emergency federal government benefit program operated by the Federal Communications Commission and, upon the conclusion of the benefit, my household will be subject to Citizens’ regular rates, terms, and conditions which is expected to be as shown on monthly bill without applied ACP discount should my household continue to subscribe to Citizens’ broadband service or standard rate selected should I upgrade during the term of the ACP program

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

I consent to Citizens 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, address, telephone number, type of service, start date of service, termination of service date, ACP Program discount amount, eligible program, Lifeline Benefit, Linkup Service Date and Independent Economic Household certification date.

I consent to Citizens verifying my household’s broadband usage each month to enable Citizens to claim reimbursement for my program benefit each month.

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

I acknowledge that I may obtain ACP-supported broadband service from any participating provider of my choosing and that I can transfer their Affordable Connectivity Programto another provider at any time.

I acknowledge that if I cannot demonstrate eligibility, I will not be enrolled in the program and/or Citizens is required to disenroll me from the program.

I acknowledge that I will not be required to pay early termination fees if I choose to terminate or modify my broadband service during my participation in the ACP, or upon receiving notice of the benefit ending.

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

I acknowledge that the Affordable Connectivity Program will not be prorated for a partial month of service and may be less than the full benefit during the final month of the program when program funding is nearing depletion.

I acknowledge that my internet service may be interrupted if my account is past due for 90 days or if my service is not used for 30 days.

To file a complaint about the ACP program, the contact information is below:

  • (877) 384-2575

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