Affordable Connectivity Program Qualification Form
Fill out the form below to find out if you qualify for a free phone and or $20 tablet with hot spot for up to 9 devices + 1 year free internet service
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Birthday
*
-
Month
-
Day
Year
Date
Last 4 of Your SSN (This is used for qualification purposes only)
*
Address (As it appears on your I.D.)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Benefit You Qualify For
*
Free and Reduced School Lunch Program
EBT/SNAP/Food Stamps
Federal Pell Grant
Veteran's and Survivors Pension Benefit
Medicaid
Supplemental Security Income
Federal Public Housing Assistance
Current Participant in FCC's Lifeline Program
Qualify based on Household Income (-$99,000 for single filers and -$198,000 joint filers)
Have you already participated in the EBB or ACP Program and was TruConnect your service provider?
*
No, I have NOT participated in the EBB or ACP
Yes, I have participated in the EBB or ACP and TruConnect was NOT my provider. If approved, I authorize changing my provider to TruConnect.
Yes, I have participated in the EBBor ACP and TruConnect was my provider.
Preferred Method of contact
Text
Email
Phone
I certify that my information is correct and authorize Wifi Mobile Solutions to enter my information into the USAC National Verifier system in order to verify my eligibility. And If approved, I understand that if I have a current Lifeline/EBB or ACP provider my services will be transferred to TruConnect and I will lose current service with my Lifeline/EBB or ACP provider.
*
Yes
I understand that if I am already enrolled in the EBB program, then each of the disclosures and consents contained herein shall apply with respect to the EBB program and to the successor ACP. I further consent to being enrolled in the ACP with TruConnect as of March 1, 2022.
*
Yes
I authorize the Company to access any records required to verify my statements on this form and to confirm my eligibility for the Lifeline program and ACP. I also authorize the Company to release any records required for the administration of the programs (including name, telephone number, address, date of birth, last 4 digits of SSN, or Tribal ID Number, amount of support being sought, means of qualification for support, and dates of service initiation and termination) to the USAC, to be used in program databases and to ensure the proper administration of the programs. Failure to consent will result in denial of benefits and/or service.
*
Yes
I acknowledge that the information I have provided on this Consent to Obtain Consumer Reports is true and accurate. I certify that I have been provided with a copy the Disclosure Concerning Consumer reports which you may obtain about me in connection with my application.
*
Yes
I give express consent for WIFI Mobile to contact me to validate my eligibility for or desire to participate in ACP offers, and other Outreach Initiatives via email, telephone, or text messaging. (Optional)
Yes
No
Initials
*
Submit
Should be Empty: