ACP Transfer-In From

ACP TRANSFER-IN FORM

Date(Required)

Account Number(Required)

Inter Mountain Cable, Coalfields Telephone and/or Mikrotec CATV Billing Account Number

ACP Application ID Number(Required)

Name(Required)

First Last

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone Number(Required)

Cell Phone Number

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:

I understand my ACP benefit will be applied to my new service and will no longer be applied to service retained from the transfer-out provider.(Required)

I may be subject to the transfer-out provider’s undiscounted rates as a result of the transfer if I elect to maintain service from the transfer-out provider.(Required)

I am aware of the one ACP benefit transfer transaction per service month.(Required)

Signature(Required)

CAPTCHA

ACP TRANSFER-IN FORM

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