ACP-Customer Opt-In

Affordable Connectivity Program (ACP)

Customer Opt-In Form

Date *

Date

Name *

Date of Birth *

Date

ACP Application ID *

Last four digits of SSN *

Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

example@example.com

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

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

Clear

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 RTC Communications will be required to de-enroll me from the program. *

Clear

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

Clear

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. *

Clear

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

Clear

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

Clear

I acknowledge I will be subject to the RTC Communications’ 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 RTC Communications, or upon de-enrollment from the ACP. *

Clear

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 calling888-225-5322. *

Clear

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

Clear

Iacknowledge that I have reviewed the available services and upload/download speedsand data caps for services offer by RTC Communications for the ACP Program. *

Clear

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

Clear

I consent to RTC Communications disclosing and/or transmitting anyinformation required to the program Administrator for my participation in theprogram including but not limited to my name, my dependent’s name, date ofbirth, last 4 digits of social security number or Tribal Identification Number,address, telephone number, type of service, start date of service, terminationof service date, ACP Program discount amount, eligible program, tribal benefitstatus, Lifeline Tribal Benefit, Linkup Service Date and Independent EconomicHousehold certification date. *

Clear

I acknowledge that if RTC Communications has a reasonable basis to believethat I am no longer eligible to receive the ACP benefit, I will receive anotification of impending termination of my ACP benefit and will have 30 daysfollowing the date of such notice to demonstrate continued eligibility. *

Clear

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

Clear

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. *

Clear

I certify that: (1) I have confirmed my eligibility for the Affordable Connectivity Program through the National Verifier.(2) I reviewed the above disclosures and consent to ACP program enrollment. *

Clear

Customer Signature *

Clear

Date Signed *

Date

IF you are transfering your ACP benefit to RTC Communications please read and initial each of the following.

I am transferring my ACP benefit to RTC Communications.

Clear

The effect of the transfer is my ACP benefit will be applied to the RTCCommunications’ service and will no longer be applied to service retained fromthe transfer-out provider.

Clear

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.

Clear

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

Clear

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.

Clear

FOR INTERNAL USE ONLY

Processing Date

Date

Employee Name

Was Customer eligibility confirmed in National Verifier?

Yes No

Benefit Amount:

NOTE: THIS RECORD AND ANY RELATED DOCUMENTATION OF ELIGIBILITY MUST BE MAINTAINED FOR A MINIMUM OF 6 YEARS AFTER THE LAST DATE THE ABOVE-NAMED CUSTOMER RECEIVED ACP BENEFITS.