ACP ENROLLMENT FORM
Proton - Privacy by default
The Affordable Connectivity Program is a long-term, $14 billion program to help ensure we can afford the internet connections we need for work, school, healthcare and more. Complete the form below to see if you qualify for a phone or a tablet with high-speed 4G internet service, hotspot, and unlimited calling/texting for up to 6 years!
*MUST BE 18+ YEARS OLD TO QUALIFY *
Are you ACTIVELY receiving services with Lifeline/ACP? (Phone/Tablet/Internet Service)
*
I AM NOT receiving another service
I AM receiving another service and would like my services transferred to the new device
You can qualify for the service if you earn less than $85,000 a year, or if you have one of the benefits listed below:
Do You Receive (select all that apply):
*
Federal Pell Grant or Financial Aid
Food Stamps (SNAP)
Medicaid
WIC
Low Income (if you earn less than $75,000 per year)
Social Security Income
Supplemental Security Income
Veteran Disability
Name (as listed on your benefit)
*
First Name
Middle Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Last Four Numbers of Your Social Security Number
*
Address (as listed on your benefit)
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Street Address
Apartment / Unit Number
City
State / Province
Postal / Zip Code
Upload Most Recent W-2 / 1099 / Form (IF QUALIFYING WITH INCOME) or Benefit Award Letter (IF QUALIFYING WITH SNAP / MEDICAID / SSI / DISABILITY / PELL GRANT / WIC / VETERAN BENEFITS)
*
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I understand there is a one-time co-payment of $23.00 (no monthly or yearly cost for up to 6 years)
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Yes
No
Submit
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