ACP Enrollment Form

The Affordable Connectivity Program is an F.C.C. benefit program that helps ensure that households can afford the broadband they need for work, school, healthcare, and more.

The Affordable Connectivity Program provides a discount of up to $30 per month toward internet service for eligible households. This covers your cost for an active account and internet provided to you by the company providing your benefit at no charge due to your qualification to the Affordable Connectivity Program.

Note: The program is limited to one monthly service discount and one device discount per household.

Who Is Eligible for the Affordable Connectivity Program?

A household is eligible for the Affordable Connectivity Program if the household income is at or below 200% of the Federal Poverty Guidelines or if a member of the family meets at least one of the criteria below:

Received a Federal Pell Grant during the current award year

Participates in one of these assistance programs:

Free and Reduced-Price School Lunch Program or School Breakfast Program, including at U.S. Department of Agriculture (USDA) Community Eligibility Provision schools.

SNAP
Medicaid
Housing Choice Voucher (HCV) Program (Section 8 Vouchers)
Project-Based Rental Assistance (PBRA)/202/811
Public Housing
Supplemental Security Income (S.S.I.)
W.I.C.
Veterans Pension or Survivor Benefits
or Lifeline;
Participates in one of these assistance programs and lives on Qualifying Tribal lands: Bureau of Indian Affairs General Assistance
Tribal TANF
Food Distribution Program on Indian Reservations
Tribal Head Start (income based)
Affordable Housing Programs for American Indians, Alaska Natives, or Native Hawaiians

This form is the first step toward the qualification process. To ensure the fluidity of the process, please fill out this form in its entirety. All information submitted must be accurate.

Note:

Any information obtained will be utilized solely to validate your qualification and an account to issue you a tablet with free service. Your information will never be sold to any third-party companies.

Name*

First NameMiddle NameLast NameSuffix

Address*

Street Address

Apt or Condo #

CityState

Zip Code

Email*

ex. JohnDoe@domain.com

Last 4 of your Social Security Number *

Your last 4 must be accurate. Any inaccuracy will DELAY your process of getting qualified.

Date of Birth*

MonthDayYear

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Which active government program do you currently receive?*

Please upload a the applicant's unexpired state ID*

ID must be clear and must match the name of the applicant applying.

Please upload a picture of your benefit card or award letter of the current year.*

(Numbers on the card may be blocked, however, name must be visable)

Will you be qualifying for the Affordable Connectivity Program through your dependant?

Name of Dependant

First NameLast Name

Date of bith

Dependant's D.O.B.

Last 4 of Social

Dependant's Last 4

YesNo

Name of Organization whom provided you with this Affordable Connectivity Program resource?

Referral name (If Applicable)

Referral number (If Applicable)

Once you press the submit button, you will complete the enrollment application.

Upon submission, allow us 24-48 hrs to be contacted by a field agent to qualify and assign the tablet to the eligible household(s).

NOTE:

If any information provided is inaccurate, additional information may be required.

Please inspect the information provided to increase the accuracy and fluidity of the process.