A. 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 household income is 200% or less than the Federal Poverty Guidelines (the amount listed in the Federal Poverty Guidelines table on this form).
B. I agree that if I move, I will give my service provider my new address within 30 days.
C. I understand that I must tell my service provider within 30 days if I do not qualify for the ACP anymore, including:
1. I, or the person in my household that qualifies, do not qualify through a government program or income anymore.
2. Either I or someone in my household gets more than one ACP benefit.
D. I know that my household can only get one ACP benefit, and, to the best of my knowledge, my household is not getting more than one ACP benefit. I understand that I can only receive one connected device (desktop, laptop, or tablet) through the ACP, even if I switch ACP providers.
E. I agree that all of the information I provide on this form may be collected, used, shared, and retained for the purposes of applying for and/or receiving the ACP benefit. I understand that if this information is not provided to the Program Administrator, I will not be able to get ACP benefits. If the laws 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 ACP Administrator. The information shared by the state or Tribal government will be used only to help find out if I can get an ACP benefit.
F. For my household, I affirm and understand that the ACP is a 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.
G. All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.
H. I know that willingly giving false or fraudulent information to get ACP benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program.
I. I was truthful about whether I am a resident of Tribal lands, as defined in the “Your Information” section of this form.