Fillable ACP About the Affordable Connectivity Program Household Worksheet

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ACP About the Affordable Connectivity Program Household Worksheet

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The ACP About the Affordable Connectivity Program Household Worksheet form is 4 pages long and contains:

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  • 137 other fields

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Page 1 of 4
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
What this worksheet is for
Use this worksheet if someone else at your address gets the Affordable Connectivity Program (ACP)
benefit. The answers to these questions will help you find out if there is more than one household
at your address.
What is a household?
A household is a group of people who live together and share income and expenses (even if they are
not related to each other).
Examples of one household:
Examples of more than one household:
• Four roommates who live together but do not share money are four households.
They can have one ACP benefit each, four total.
• 30 seniors who live in an assisted-living home but do not share money are 30
households. They can have one ACP benefit each, 30 total.
Household expenses
A household shares expenses. Household expenses include, but are not limited to, food,
healthcare expenses, and the cost of renting or paying a mortgage on your place of residence and
utilities.
Income
Households share income. Income includes salary, public assistance benefits, social security
payments, pensions, unemployment compensation, veteran’s benefits, inheritances, alimony,
child support payments, worker’s compensation benefits, gifts, and lottery winnings.
About the
ACP
The ACP is a Federal
Communications
Commission
(FCC) program that
provides a broadband
and/or one-time
connected device
benefit for qualifying
low-income
consumers.
FCC FORM 5646
Affordable Connectivity Program
Household Worksheet
• A married couple who live together are one household. They must share one
ACP benefit.
• A parent/guardian and child who live together are one household. They must
share one ACP benefit.
• An adult who lives with friends or family who financially support him/her are
one household. They must share one ACP benefit.
Page 2 of 4
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
1. What is your full legal name?
The name you use on official documents, like your Social Security Card or State ID. Not a nickname.
First
Middle (optional)
Suffix (optional)
Last
2. What is your home address? (The address where you will get service. Do not use a P.O. Box)
Street Number and Name
City
Zip Code
State
Apt., Unit, etc.
Your
Information
All fields are required
unless indicated. Use only
CAPITALIZED LETTERS
and black ink to fill out
this form.
FCC FORM 5646
Affordable Connectivity Program
Household Worksheet
Page 3 of 4
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
You do not qualify for the ACP because someone in your
household already gets the benefit. You are only allowed to get one
ACP benefit per household, not per person.
Check this box
Can you
apply?
Follow this decision tree
to confirm if you qualify
for the ACP.
You can apply for the ACP.
You live at an address with
more than one household
and your household does
not get the ACP benefit yet.
Please initial lines
A
and
B
on page 4,
and
sign and date the worksheet.
Check this box
Yes No
Adults are people who are 18 years old or older, or who are emancipated
minors. This can include a spouse, domestic partner, parent, adult
son or daughter, adult in your family, adult roommate, etc.
Yes No
3. Do you share money (income and expenses)
with them?
This can be the cost of bills, food, etc., and income. If you are married,
you should check yes for this question.
Yes No
If yes, answer
question 3
If yes, answer
question 2
4. Please check the box that best describes the building where you live:
Other: (please describe)
5. If you live at a single family home where three or more economic households have applied for the ACP, please
identify the number of individuals who reside at the address and the number of people in your economic
household:
Number of people at address: ______________ Number of people in your economic household: _______________
_________________________________________
Apartment building
Transitional housing or shelter
Single family home
Residential facility (such as a nursing home or assisted living facility)
You can apply for the
ACP. You live in a
household that does not
get the benefit yet.
Please initial line
B
on
page 4, and sign and
date the worksheet.
Check this box
FCC FORM 5646
Affordable Connectivity Program
Household Worksheet
1. Do you live with another adult?
2. Do they get the ACP benefit?
Page 4 of 4
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
Privacy Act Statement
This Privacy Act Statement explains how we are going to use the personal information you are entering into this form.
The Privacy Act is a law that requires the Federal Communications Commission (FCC) and the Universal Service Administrative Company
(USAC) to explain why we are asking individuals for personal information and what we are going to do with this information after we
collect it.
Authority: 47 U.S.C. §254; Consolidated Appropriations Act, 2021, Public Law 116–260, div. N, tit. IX, § 904, as modified by the
Infrastructure Investment and Jobs Act, Public Law 117-58, div. F, tit. V, secs. 60501, 60502(a)-(b); 47 CFR Part 54, Subparts E and P.
Purpose: We are collecting this personal information so we can verify your identity and that you qualify for the Lifeline program or
similar programs that use income or consumer participation in certain government benefit programs as eligibility criteria, such as the
Affordable Connectivity Program. We access, maintain and use your personal information in the manner described in the Lifeline System
of Records Notice (SORN), FCC/WCB-1, and the Affordable Connectivity Program SORN, formerly known as the Emergency Broadband
Benefit Program SORN, FCC/WCB-3, both available at https://www.fcc.gov/managing-director/privacy-transparency/privacy-act-
information#systems/.
Routine Uses: We may share the personal information you enter into this form with other parties for specific purposes, such as:
• With contractors that help us operate the Lifeline program and similar programs that use income or consumer participation in
certain government benefit programs as eligibility criteria, such as the Affordable Connectivity Program;
• With other federal and state government agencies and Tribal agencies that help us determine your Lifeline eligibility and eligibility
for similar programs that use income or consumer participation in certain government benefit programs as eligibility criteria, such
as the Affordable Connectivity Program;
• With the telecommunications companies and broadband providers that provide you Lifeline service and service under a similar
program that uses income or consumer participation in certain federal benefit programs as eligibility criteria, such as the
Affordable Connectivity Program;
• With other federal agencies o
r to other administrative or adjudicative bodies before which the FCC is authorized to appear;
• With appropriate agencies, entities, and persons when the FCC suspects or has confirmed that there has been a breach of
information; and
• With law enforcement and other officials investigating potential violations of Lifeline and other program rules.
A complete listing of the ways we may use your information is published in the Lifeline SORN and the Affordable Connectivity Program
SORN (formerly known as the Emergency Broadband Benefit Program SORN) described in the "Purpose" paragraph of this statement.
Disclosure: You are not required to provide the information we are requesting, but if you do not, you will not be eligible to receive
Lifeline services under the Lifeline Program rules, 47 C.F.R. Part 54, Subpart E, or benefits under the Affordable Connectivity Program
rules, 47 C.F.R. Part 54, Subpart P.
Initial
A
6. I live at an address with more than one household.
Initial
B
7. I understand that the one-per-household limit is a Federal Communications Commission
(FCC) rule and I will lose my Affordable Connectivity Program benefit if I break this rule.
8. Signature
9. Today’s Date
Agreement
Please initial the
agreement below and
sign and date this
worksheet. Submit this
worksheet with your
Affordable Connectivity
Program Application
Form.
I consent to let USAC contact me at the phone
number I provided for important reminders and
updates to my ACP service. Message and data
rates may apply. Text STOP to end messages.
FCC FORM 5646
Affordable Connectivity Program
Household Worksheet
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Completed 14 February 2022

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