ACP TRANSFER-IN FORM

MM slash DD slash YYYY
Inter Mountain Cable, Coalfields Telephone and/or Mikrotec CATV Billing Account Number
Name(Required)
Billing Address(Required)

I give my affirmative consent to transfer my ACP benefit to Gearheart Broadband (Inter Mountain Cable, Coalfields Telephone and Mikrotec CATV) and agree and certify that: