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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 monthly
internet service
discount and a one-
time connected
device benefit from
participating
internet companies
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 fastest processing.
Mail the form to this address:
USAC
ACP Support Center
P.O. Box 7081
London, KY 40742
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the ACP 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 and up to $75 for qualifying households on Tribal lands.
Through the program, your internet company 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 company. You are only allowed to get one
ACP benefit per household, not per person.
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: Internet companies must also meet certain criteria to participate in the ACP. Check with your
company 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). Complete the ACP household worksheet to determine if more than one qualifying
household is located at your address. If more than one person in your household participates in the ACP,
you are breaking the FCC's rules and will lose your benefit.
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. Please include copies of your proof documentation when you submit your application to
speed up processing time.
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 ACP 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 providing 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 ACP 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 ACP 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 providing 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 ACP 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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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. 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 2022 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 ACP Support Center at 1-877-384-2575
1
$27,180 $33,980 $31,260
Yes No
2
$36,620 $45,780 $42,120
Yes No
3
$46,060 $57,580 $52,980
Yes No
4
$55,500 $69,380 $63,840
Yes No
5
$64,940 $81,180 $74,700
Yes No
6
$74,380 $92,980 $85,560
Yes No
7
$83,820 $104,780 $96,420
Yes No
8
$93,260 $116,580 $107,280
Yes No
If more than 8, add this
amount for each extra person:
Add $9,440
Add $11,800 Add $10,860
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 internet company my new address within 30 days.
19. I understand that I have to tell my internet company 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 companies.
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 company’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.
The certification below applies to all consumers and is required to process your application.
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.
By providing a phone number, you
consent to letting USAC contact
you at that phone number via
artificial or prerecorded voice
message or text for important
reminders and updates about your
ACP benefit. For text messages,
message and data rates may apply.
Text STOP to end messages.
Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the ACP 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
Representatives who help
consumers apply (such as
internet company agents,
state and Tribal partners,
etc.) are required to register
in the Representative
Accountability Database
(RAD) and must enter their
Representative ID here.
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 ACP 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; 47 U.S.C. §1752; 47 CFR Part 54, Subparts E, P, and R
.
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 and R.
• Empowering consumers to choose the service plan that best meets their needs (including a plan they may already be on);
• Ensuring consumers have access to supported internet services regardless of their credit status;
• Prohibiting companies from excluding consumers with past due balances or prior debt from enrolling in the program;
• Preventing consumers from being forced into more expensive or lower quality plans in order to receive the ACP;
• Reducing the potential for bill shock or other financial harms;
• Allowing ACP recipients to switch companies or internet service offerings; and
• Providing a dedicated FCC process for ACP complaints at https://consumercomplaints.fcc.gov.
How Does the ACP Protect Consumers?
The rules protect Affordable Connectivity Program recipients by:
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Completed 12 April 2022

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