Name(Required) First Last Email(Required) Phone(Required)Date of Birth(Required) MM slash DD slash YYYY Last 4 SSN or Tribal ID(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Benefit Qualifying Person (if different from above) Application ID (this will be on the verification form you receive from the FCC)(Required) You must agree to all of the following conditions in order to apply for the affordable connectivity program discount:(Required) I acknowledge that by checking this box and the checkboxes below I understand that I agree with and inital each item listed.(Required) I (or my dependent or other person in my household) currently get benefits from the government program(s) listed on this form or my annual income is 200% or less than the federal poverty guidelines.(Required) For my household, I affirm and understand that the Affordable Connectivity Program is a temporary federal government subsidy that reduces my broadband internet access service bill and at the conclusion of the program, my household will be subject to the provider's undiscounted general rates, terms and conditions if my household continues to subscribe to the service.(Required) I agree that if I move I will give my service provider my new address within 30 days.(Required) I understand that I have to tell my service provider within 30 days if I do not qualify for Affordable Connectivity Program anymore, including: I, or the other person in my household that qualifies, do not qualify through a government program or income anymore. Either I or someone in my household gets more than one Affordable Connectivity Program benefit.(Required) I know that my household can only get one Affordable Connectivity Program benefit and, to the best of my knowledge, my household is not getting more than one Affordable Connectivity Program benefit. I understand that I can only receive one connected device discount (desktop, laptop, or tablet) through the Affordable Connectivity Program, even if I switch participating providers.(Required) I agree that all of the information I provide on this form may be collected, used, shared, and retained for the purpose of applying for and/or receiving the Affordable Connectivity Program benefit. I understand that if this information is not provided to the Program Administrator, I will not be able to get a Affordable Connectivity Program benefits. If the law of my state or Tribal government require it, I agree that the state or Tribal government may share information about my benefits for a qualifying program with the Affordable Connectivity Program Administrator. The information shared by the state or Tribal government will be used only to help find out if I can get an Affordable Connectivity Program benefit.(Required) All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.(Required) I know that willingly giving false or fraudulent information to get Affordable Connectivity Program benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program.(Required) I was truthful about whether or not I am a resident of Tribal lands, as defined in this form.SignatureDate MM slash DD slash YYYY Δ
