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AFFORDABLE CONNECTIVITY PROGRAM (ACP) OPT-IN FORM

Date
Application ID Number
Customer Name
Date of Birth
Address
City
State
Zip Code
Telephone Number
Mobile Number
Email Address

Eligible Qualifying Person within household other than Account Holder and date
of birth(DOB):

Name
Last 4 SSN
Date of Birth

Please read and initial each of the following to participate in the ACP Program:

I hereby opt-in to the Affordable Connectivity Program (ACP).



I acknowledge that I am aware of the eligibility requirements for the ACP. If I
can't demonstrate eligibility, I will not be enrolled in the program and/or
[Company] will be required to de-enroll me from the program.



I acknowledge the ACP is a government program that reduces my broadband internet
access service bill.



I acknowledge that I may obtain ACP-supported broadband service from any
participating provider of my choosing and that I can transfer my ACP benefit to
another provider one time a month.



I acknowledge I may apply the ACP benefit to any broadband service offering of
[Company] at the same terms and available to households that are not eligible
for the ACP supported service.



I acknowledge my provider may disconnect my ACP supported service after 90
consecutive days of non-payment.



I acknowledge I will be subject to the [Company]'s undiscounted rates and
general terms and conditions if the ACP ends, if I transfer my benefit to
another provider but continue to receive service from [Company], or upon
de-enrollment from the ACP.



I acknowledge I may file a complaint regarding an ACP supported service or any
difficulty enrolling with a provider via the Commission's Consumer Complain
Center at https://consumercomplaints.fcc.gov/hc/en-us or by calling
888-225-5322.



I acknowledge that the ACP Program is non-transferable and that the discount is
limited to one ACP discount per household, and I further certify that no other
member of my household is receiving a benefit under the ACP.



I acknowledge that I have reviewed the available services and upload/download
speeds and data caps for services offer by [Company] for the ACP Program.



I consent to applying my ACP program benefit to the broadband Internet access
service I receive from [Company].



I consent to [Company] disclosing and/or transmitting any information required
to the program Administrator for my participation in the program including but
not limited to my name, my dependent's name, date of birth, last 4 digits of
social security number or Tribal Identification Number, address, telephone
number, type of service, start date of service, termination of service date, ACP
Program discount amount, eligible program, tribal benefit status, Lifeline
Tribal Benefit, Linkup Service Date and Independent Economic Household
certification date.



I acknowledge that if [Company] has a reasonable basis to believe that I am no
longer eligible to receive the ACP benefit, I will receive a notification of
impending termination of my ACP benefit and will have 30 days following the date
of such notice to demonstrate continued eligibility.



I acknowledge that my participation in the ACP does not relieve my obligations
to adhere to [Company]'s posted rates, terms and conditions, or other rules and
regulations or tariffs that govern the services I receive.



I acknowledge that the monthly ACP Benefit will not be prorated but may be less
than the full benefit during the first and final month of the program.



I certify that:

 1. I have confirmed my eligibility for the Affordable Connectivity Program
    through the National Verifier.
 2. I reviewed the above disclosures and consent to ACP program enrollment.



I certify that: (1) I have confirmed my eligibility for the Affordable
Connectivity Program through the National Verifier using: (Select One)

Select Eligibility Program Lifeline Medicaid Supplemental Nutrition Assistance
Program (SNAP) Supplemental Security Income (SSI) Federal Public Housing
Assistance (FPHA) Gross household income at or below 200 percent of the Federal
Poverty Guidelines WIC Free and Reduced Price School Lunch Program or School
Breakfast Program Pell Grant
Name of School

Are you transferring your ACP benefit from another company to Citizens?

Yes No

Please read and initial each of the following to transfer to Citizens in the ACP
Program:

I am transferring my ACP benefit to Citizens.



The effect of the transfer is my ACP benefit will be applied to the Citizens's
service and will no longer be applied to service retained from the transfer-out
provider.



I may be subject to the transfer-out provider's undiscounted rates because of
the transfer if I elect to maintain service from the transfer-out provider.



I am limited to one ACP benefit transfer transaction per service month, with
limited exceptions for situations where the subscriber seeks to reverse and
unwanted transfer or is unable to receive service from a specific provider.



I acknowledge that I was provided and read the disclosures herein, and that I
give my informed consent to transfer my benefit to the transfer-in provider on
the date indicated next to my signature.



Clear Signature

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