Call Back Form

The Affordable Connectivity Program (ACP) is a U.S. government program that helps many low income households pay for broadband service and internet connected devices.

Full Name *

First Name Last Name

Phone Number *

Email *

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Who receives government assistance? *

Myself Somebody else in household

SSN(Social Security) Last 4 Digits *

Date of Birth *

Full Name

First Name Last Name

Qualifying Beneficiary Details SSN(Social Security) Last 4 Digits

Qualifying Beneficiary Details Date of Birth

Federal Assistance Programs | You are eligible for the ACP if you (or someone in your household) participate in one of these programs: *

Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps Medicaid Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Supplemental Security Income (SSI) Federal Public Housing Assistance (FPHA) Veterans Pension and Survivors Benefit Free and Reduced-Price School Lunch Program or School Breakfast Program, including at U.S. Department of Agriculture (USDA) Community Eligibility Provision schools Received a Federal Pell Grant in the current award year Based on your income

Based on Your Income
You are eligible for the ACP if your income is 200% or less than the Federal Poverty Guidelines (see the table below). The guideline is based on your household size and state.

The table below reflects the income limit by household size, which is 200% of the 2022 Federal Poverty Guidelines.

REQUIRED: W-2(2021) OR Current Award-Benefit Letter(2022) Required for Medicare, Income Based, Veteran Pension & Survivor Benefits

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Affordable Connectivity Program Application

* ONLY if you chose somebody else in household