2022 Affordable Connectivity Program (ACP) Information Release and Acknowledgment Authorization

Affordable Connectivity Program (ACP) Information Release and Acknowledgment Authorization
The Affordable Connectivity Program (ACP) is a financial benefit program provided by the Universal Service Fund and the Federal Communications Commission (FCC) that makes essential broadband more affordable for low-income households. The program offers a monthly credit toward broadband internet charges for those who qualify.

First, you must qualify for one of the set criteria listed on the FCC ACP website. acpbenefit.org

Second, you must complete the ACP program sign up form online at: acpbenefit.org

Third, So Red Bolt Broadband, Powered by CDEC (Continental Divide Electric Cooperative, Inc can verify your eligibility in the program you must authorize the release of your information.
Name of Red Bolt Broadband Acct. Holder*
Application ID*
Address*
Phone*
Email*
example@example.com
Birthdate*

MonthDayYear
Date
Last four of SSN or Tribal ID*
If the information above is different from the qualifying person, please provide the following information:
Full Name of Qualifying Person*
Birthdate*

MonthDayYear
Date
Last four of SSN or Tribal ID*
Consumer Protection - Enrollment Notifications
1. The ACP is a government program that reduces broadband internet access service bill.
2. The household may obtain ACP support broadband from any provider.
3. The household may apply benefit to any qualifying service with same Terms & Conditions.
4. Provider may disconnect the household's ACP service after 90 consecutive days of nonpayment.
5. Household will be subject to non-discounted rates and Terms & Conditions upon de-enrollment.
6. Household may file a complaint with FCC.
7. Consent to transmit data to National Lifeline Accountability Database (NLAD).
I have read and understand my Consumer Protections under the ACP Benefit:
Signature*

Clear
Date

MonthDayYear
Date
Information Release and Acknowledgement Authorization
I, (full name)*
Type full name
give permission to the Universal Service Administration Company toverify to Red Bolt Broadband/Continenta Divide Electric Cooperative, Inc. or its authorized agent, whether I participate in a low-income assistance program that would qualify me for the Affordable Connectivity Program. Red Bolt Broadband/Continental Divide Electric Cooperative, Inc. or its authorized agent shall maintain the information in the form and any information received about me from the department as confidential customer account information. I understand completion of this form does not constitute immediate acceptance into this program.
Signature*

Clear
Date

MonthDayYear
Date
200 East High Street / PO Box 1087 / Grants, New Mexico 87020 / redboltbroadband.con / Ph: 505.658.2487 / Fx: 505.287.2234
Should be Empty:

Affordable Connectivity Program (ACP) Information Release and Acknowledgment Authorization

Consumer Protection - Enrollment Notifications

I have read and understand my Consumer Protections under the ACP Benefit:

Information Release and Acknowledgement Authorization