ACP Consent Form

The Affordable Connectivity Program is a government program that reduces the customer’s broadband internet access service bill;
The household may obtain ACP-supported broadband service from any participating provider of its choosing;
The household may apply the ACP benefit to any broadband service offering of the participating provider at the same terms available to households that are not eligible for ACP-supported service;
The provider may disconnect the household’s ACP-supported service after 90 consecutive days of non-payment;
The household will be subject to the provider’s undiscounted rates and general terms and conditions if the program ends, if the consumer transfers their benefit to another provider but continues to receive service from the current provider, or upon de-enrollment from the Affordable Connectivity Program; and
The household may file a complaint against its provider via the Commission’s Consumer Complaint Center.

Affordable Connectivity Program Application Form

This is the only form for application to the Affordable Connectivity Program.

Application Date*
MM slash DD slash YYYY
Account Number*

Please provide account number that is on your current bill.
What is your Affordable Connectivity Program ID Number?*

Please provide the Affordable Connectivity Program (ACP) ID Number that was given to you when you enrolled.
How did you Qualify?*
- Veteran
- SNAP
- Medicaid
- Supplemental Security Income (SSI)
- Federal Public Housing Assistance (FPHA)
- FREE / Reduced School Lunch
- Federal Pell Grant
Please select one
Name*
First Last
Subscriber Birth Date*
Please Fill in your year of birth
Billing Address*
Street Address Address Line 2 City State ZIP Code
Telephone Number*
Please provide the best number to reach you at
Email
Enter Email Confirm Email
Subscriber Consent
AFFORDABLE CONNECTIVITY PROGRAM QUALIFICATION FORM

By signing this form, I give my affirmative consent that I want to participate in the Affordable Connectivity Program through Inter Mountain Cable, Coalfields Telephone or Mikrotec CATV and that I understand and certify that:
- ACP provides a discount of up to $30 per month depending on price of the service tier or bundle. If the total bill exceeds $30 per month, I will be responsible for the remaining balance after the ACP discount is applied. This includes any taxes and required fees that are applied to the full amount of the service.*
- I am either a current Lifeline customer or my eligibility has been verified by the National Verifier so that I qualify for the ACP.*
- Due to the temporary nature of this program, the ACP monthly benefit may be less than the full benefit during the final month of the program when program funding is nearing depletion.*
- My existing Lifeline discount, if it is currently being applied to internet service, will be applied to my bill first, then the ACP credit will be applied.*
- My household may obtain broadband service supported by the ACP from any participating provider of my choosing and I may transfer my ACP benefit to another provider at any time.*
- I may only receive one ACP benefit per household, from one participating provider, and I certify that no other member of my household is receiving an emergency broadband benefit under the ACP.*
- All official communications for ACP will be via electronic mail or text messaging and I consent to receive such communications from Inter Mountain Cable, Gearheart TV, Coalfields & Mikrotec CATV*
- Due to the temporary nature of this program, the ACP monthly benefit may be less than the full benefit during the final month of the program when program funding is nearing depletion.*
- I agree that all 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 ACP Program Administrator, I will not be able to get ACP benefits.*
- Inter Mountain Cable, Gearheart TV, Coalfields & Mikrotec CATV will notify me of the end date of the ACP and give me the opportunity to opt-in to continue receiving my broadband service plan to which I am subscribed under the ACP by paying the regular rates, terms, and conditions for the plan. If I do not opt-in, Inter Mountain Cable, Gearheart TV, Coalfields & Mikrotec CATV will discontinue providing the broadband internet service plan I have been receiving under the program.*
- When the Affordable Connectivity Program (ACP) ends and I opt to keep my broadband service plan when the rates return to standard non-discounted rates, the rates, including fees, and taxes.*
- Any Benefit Qualifying Person ( BQP) can only qualify for one household.*
Consent*
I consent to all fields/questions that are presented above.
Terms of Service Agreement*
I CONSENT to ALL Terms of Service agreement(s) that are associated with the Affordable Connectivity Program provided by this link: Gearheart Terms of Service
Signature Needed
Signature*
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Affordable Connectivity Program Application Form

Subscriber Consent

AFFORDABLE CONNECTIVITY PROGRAM QUALIFICATION FORM

By signing this form, I give my affirmative consent that I want to participate in the Affordable Connectivity Program through Inter Mountain Cable, Coalfields Telephone or Mikrotec CATV and that I understand and certify that:

Signature Needed

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