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WHOOPCONNECT ACP BENEFIT APPLICATION
How would you like to be contacted about your status or if further verification is needed?
*
Phone
Text Message
Email
Name
*
First Name
Last Name
Email
*
example@example.com
Last 4 of SSN
*
1234
Address ***Please use address that can be verified with the Benefit you are using!
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
What Government Benefit(s) are You or your Qualifying person using?
*
SNAP (Food Stamps)
Medicaid (Attach a picture of card)
Free School Breakfast/Lunch (Enter child's info)
Federal Pell Grant
SSi
Section 8
Apply Based On Income (Attach W-2)
WIC
Veterans Pension or Survivors Benefit
Other
Who Receives Government Benefits?
*
Myself
My Child (Complete entire form)
Both (Complete entire form)
Someone else in my household- Qualifying person (Complete entire form)
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Please complete the section below, if you are applying through your child child or someone else in your household.
Name of Qualifying person
First Name
Last Name
Last 4 of SSN of Qualifying person
XXX-XX-1234
Date of birth of Qualifying person
-
Month
-
Day
Year
Date
Name of School - If Applicable of Qualifying person
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Documents needed to upload. (Optional)
It will speed up the process if you upload your qualifying documents. If you do not upload your documents please check for an email, text, or phone call if further verification is needed.
Verification letter: SNAP, Food Stamps, Medicaid, Pell, SSI, Section 8, Pension Letters
Browse Files
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Choose a file
Please upload any verification letters.
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Card Verification - SNAP, Food Stamps, Medicaid Card
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Please upload a picture of any cards that can verify your enrollment in qualifying program.
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In the event you are not eligible for the ACP Tablet, what option is preferred?
Please Select
FREE SIM Card- can be used in any device
FREE Cellphone
Contact Me at my preferred contact method
Signature
Please verify that you are human and you authorize the submission of your ACP application through WhoopConnect
*
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Submit
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