Form
Name
*
First Name
Middle Name
Last Name
Last 4 Digits (SSN)
*
[*NOTE: If you have a TIN, enter 0000]
Date of Birth
*
/
Month
/
Day
Year
Who receives government assistance?
*
Myself
Somebody else in household
Name
*
First Name
Middle Name
Last Name
Last 4 Digits (SSN)
*
[*NOTE: If they have a TIN, enter 0000]
Date of Birth
*
/
Month
/
Day
Year
Street Address where you RECEIVE your benefit - [Do not use a P.O. Box or business address]
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you live with another adult? - (Adults are people who are 18 years or older, or who are emancipated minors. This can include a spouse, domestic partner, parent, adult son or daughter, adult in your family, adult roommate, etc.)
*
YES
NO
Do they get the Affordable Connectivity Program?
*
YES
NO
Do you share money (income and expenses) with another adult who gets the Affordable Connectivity Program Benefit? - (This can be cost of bills, food, etc., and income. If you are married, you should click yes for this question.)
*
YES
NO
We are sorry. You do not qualify for the Affordable Connectivity Program. This is because someone in your household already gets the benefit. You are only allowed to get one Affordable Connectivity Program benefit per household, not per person.
Qualify: Select the applicable program from below to show that you, your dependent, or someone in your household qualifies for the Affordable Connectivity Program.
*
Please Select
Medicaid
SNAP (Food Stamps)
Supplemental Security Income (SSI)
Federal Public Housing Assistance
Veterans Pension or Survivors Benefit Program
WIC
Federal Pell Grant
National School Lunch/Breakfast Program
Apply based on income (200% of federal poverty guidelines)
You can qualify through one of the programs below OR through your income. You may only select one option.
Public Housing Options
*
Please Select
Housing Choice Voucher Program
Project-based rental assistance
Public housing
Beneficiary's School Name
*
If Your Income Is At Or Below 200% Of The Federal Poverty Guidelines, As Shown Below, You Can Qualify For ACP.
Guidelines (Annual Income): 1 Person = $29,160 2 People = $39,440 3 People = $49,720 4 People = $60,000 5 People = $70,280 6 People = $80,560 7 People = $90,840 8 People = $101,120 Each Additional Person = $10,280
How many people in your household?
*
State the School Is In
*
School District the School Is In
*
School Name
*
By checking the “Terms of Enrollment” box above and signing below, I certify, under penalty of perjury, that all the information in my application is true. I also certify that I have read and agreed to the Terms of Enrollment.
*
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