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About the ACP Affordable Connectivity Program Application Form

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FCC FORM 5645
Affordable Connectivity Program
Application Form
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.
Apply
To apply for the ACP, fill out the required sections of this form,
initial every agreement statement, and sign on page 7. You can
also apply online at ACPbenefit.org for faster processing.
Mail the form to this address:
USAC
Affordable Connectivity Support Center
P.O. Box 7081
London, KY 40742
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
Rules
If you qualify, your household can receive a monthly Affordable Connectivity Program (ACP) benefit of up
to $30 to cover the cost of your internet service (up to $75 on qualifying Tribal lands). Through the
program, your service provider may also offer a one-time internet connected device benefit of up to $100
for a computer, tablet, or laptop with a co-payment of more than $10 but less than $50.
Your household cannot get the ACP benefit from more than one service provider. You are only allowed to
get one ACP benefit per household, not per person. If more than one person in your household
participates in the ACP, you are breaking the FCC’s rules and will lose your benefit.
The Affordable Connectivity Program is separate from the FCC's Lifeline Program. If your household
qualifies for both programs, you can apply for and receive both benefits.
Note: Broadband service providers must also meet certain criteria to participate in the ACP. Check with
your service provider to determine if it participates.
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).
Do not give your benefit to another person
The ACP benefit is non-transferable. You cannot give your benefit to another person, even if they qualify for
the ACP.
Be honest on this form
You must give accurate and true information on this form and on all ACP related forms or questionnaires. If
you give false or fraudulent information, you will lose your benefit (i.e., de-enrollment or being barred from
the program) and the United States government can take legal action against you. This may include (but is
not limited to) fines or imprisonment.
You may need to show other documents
If the ACP Administrator is not able to validate that you or someone in your household qualify by checking
available electronic resources (including eligibility databases for the FCC's government agency partners),
you may need to provide additional documents. For example, you may need to provide an official
document that proves your participation in a qualifying government assistance program, your income, or
your identity.
Page 1 of 8
Your
Information
All fields are required
unless indicated. Use only
CAPITALIZED LETTERS
and black ink to fill out
this form.
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
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FCC FORM 5645
Affordable Connectivity Program
Application Form
Page 2 of 8
What is your full legal name?
The name you use on official documents, like your Social Security Card or State ID. Not a nickname.
3. What is your date of birth?
Month Day Year
4. What is your email address?
2. What is your phone number (if you have one)?
First
Middle (Optional)
Last
(Recommended)
5. I
dentity Verification. Please select one of the following:
a. If you would like to verify your identity using your Social Security number, please enter the
last four digits of your Social Security number (SSN4)*
*
Social Security numbers are not required to participate in the Affordable Connectivity
Program, but using a Social Security number will process your application the fastest.
b. If you have and would like to use a Tribal Identification Number to verify your identity,
please enter it below.
c. Driver’s License, Military ID, Passport, Taxpayer Identification Number (ITIN), or other
Government ID. Please select the type of identification you would like to use to verify your identity.
Driver’s License
Military ID
Passport
Taxpayer Identification Number
Other Government ID
Please include a scanned copy or photo of your form of identification with your application.
Suffix (optional)
Your
Information
(continued)
* Tribal lands include any
federally recognized Indian
tribe’s reservation, Pueblo, or
colony, including former
reservations in Oklahoma;
Alaska Native regions
established pursuant to the
Alaska Native Claims
Settlement Act (85 Stat. 688) ;
Indian allotments; Hawaiian
Home Lands—areas held in
trust for Native Hawaiians by
the state of Hawaii, pursuant
to the Hawaiian Homes
Commission Act, 1920 July 9,
1921, 42 Stat. 108, et. seq., as
amended; and any land
designated as such by the FCC
pursuant to the designation
process in the FCC’s Lifeline
rules.
A map of qualifying Tribal
lands is available on USAC's
website: https://
www.usac.org/wp-content/
uploads/lifeline/documents/
tribal/
fcc_tribal_lands_map.pdf.
6. What is your home address? (The address where you will get service. Do not use a P.O. Box.)
Street Number and Name
CityApt., Unit, etc.
State
Zip Code
7. Is this a temporary address?
Yes
No
8. Check if you live on Tribal lands*
9. What is your mailing address? (Only fill this out if it is not the same as your home address.)
Street Number and Name
City
Zip Code
State
Apt., Unit, etc.
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
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Application Form
Page 3 of 8
Your
Information
(continued)
10. Check if you are qualifying through a child or dependent in your household. If
so, answer the following questions:
11. What is their full legal name?
Only fill this section
out if you are
applying through a
child or dependent.
First
Month Day Year
Middle (optional)
Suffix (optional)
Last
12. What is their date of birth?
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
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Affordable Connectivity Program
Application Form
Page 4 of 8
c. Driver’s License, Military ID, Passport, Taxpayer Identification Number (ITIN), or other
Government ID. Please select the type of identification you would like to use to verify their identity.
Driver’s License
Military ID
Passport
Taxpayer Identification Number
Other Government ID
Please include a scanned copy or photo of their form of identification with your application.
*
Social Security numbers are not required to participate in the Affordable Connectivity
Program, but using a Social Security number will process your application the fastest.
b. If you have and would like to use a Tribal Identification Number to verify their identity,
please enter it below.
13. I
dentity Verification. Please select one of the following:
a. If you would like to verify their identity using their Social Security number, please enter the
last four digits of their Social Security number (SSN4)*
14. Check all programs that you or someone in your household have:
Qualify through a government program:
Or
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
Bureau of Indian Affairs (BIA) General Assistance
Tribal Temporary Assistance for Needy Families (Tribal TANF)
Food Distribution Program on Indian Reservations (FDPIR)
Tribal Head Start (only households that meet the income qualifying standard)
Tribal Specific Programs
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FCC FORM 5645
Affordable Connectivity Program
Application Form
Page 5 of 8
Supplemental Nutrition Assistance Program (SNAP, also called Food Stamps)
Supplemental Security Income (SSI)
Medicaid
Federal Public Housing Assistance (FPHA)
Veterans Pension or Survivors Benefit Programs
Federal Pell Grant for the current award year
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Free and Reduced Price School Lunch or Breakfast Program, or enrollment in a
Community Eligibility Provision School for the 2019-20, 2020-21, or 2021-22 school year. If
you choose this program, please enter your school name, school district and state.
School Name
School District
State
Qualify for
the ACP
Fill out this section to
show that you, your
dependent, or someone
in your household
qualifies for the ACP.
You can qualify through
certain government
assistance programs or
through your income (you
do not need to qualify
through both).
When you mail this form,
please include
documents that show
you participate in one of
the programs you
selected or that you
qualify through your
income. A list of
acceptable documents is
available at
ACPbenefit.org.
Is your income the same or less than the amount listed for
your state and household size?
(only check yes or no next to your household size)
All 48 States, DC,
and Territories
Alaska Hawaii
200% of the 2021 Federal Poverty Guidelines
*The Federal Poverty Guidelines are typically updated at the end of January.
many people live in your
household? (check one)
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
1
$25,760 $32,180 $29,640
Yes No
2
$34,840 $43,540 $40,080
Yes No
3
$43,920 $54,900 $50,520
Yes No
4
$53,000 $66,260 $60,960
Yes No
5
$62,080 $77,620 $71,400
Yes No
6
$71,160 $88,980 $81,840
Yes No
7
$80,240 $100,340 $92,280
Yes No
8
$89,320 $111,700 $102,720
Yes No
If more than 8, add this
amount for each extra person:
Add $9,080 Add $11,360 Add $10,440
Yes No
Qualify through your income:
Qualify for
the ACP
15. Including you, how
16.
(continued)
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FCC FORM 5645
Affordable Connectivity Program
Application Form
Page 6 of 8
17. 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).
18. I agree that if I move I will give my service provider my new address within 30 days.
19. I understand that I have to 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.
20. 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.
21. 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.
22. 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.
23. All the answers and agreements that I provided on this form are true and correct to the
best of my knowledge.
24. 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.
25. I was truthful about whether or not I am a resident of Tribal lands, as defined in the
"Your Information" section of this form.
FCC FORM 5645
Affordable Connectivity Program
Application Form
Agreement
I agree, under
penalty of perjury,
to the following
statements:
You must initial next to
each statement. If you
fail to initial each
statement, your
application will be
considered incomplete.
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Initial
Page 7 of 8
26. Signature
27. Today's Date
Representative
Information
Answer only if a Service
Provider Representative
submits this form.
28. What is your Representative ID?
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FCC FORM 5645
Affordable Connectivity Program
Application Form
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
Page 8 of 8
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 or 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.
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