Emergency Broadband Benefit
Program (EBBP) Consent
I, __________________________, hereby provide my written consent that Golden West
Telecommunications can enroll me in the Emergency Broadband Benefit Program (EBBP).
I am qualified for
Lifeline and EBBP (check one box). I understand the
EBBP is a government program that 1) began on May 12, 2021, 2) reduces my broadband
internet access bill and 3) is temporary. The program will end once the funds are exhausted,
or six months after the Department of Health and Human Services declares an end to the
pandemic, whichever comes first. Once the program ends, I understand that my monthly bill
will revert to the full monthly charges less any discounts and plus any taxes and surcharges,
based on the terms and conditions of my agreement with Golden West.
The EBBP may end in the middle of the billing cycle resulting in less than the full monthly
service credit for the final month of the program. If there is a partial benefit in the last
month of the program, I understand I will be charged an amount higher than what I would
pay if the full EBBP benefit were applied to my broadband bill.
I understand that I may obtain EBBP support from any EBB participant and I can transfer
my Emergency Broadband Benefit to another EBB participant at any time.
Please consider your service options after the EBBP has ended and indicate your choice:
I wish to continue my broadband service with Golden West after the
EBBP has ended.
I do not wish to continue my broadband service with Golden West after
the EBBP has ended.
Signature: ____________________________________ Date: ___________________
Printed Name: ________________________________
Contact Phone: ________________________________
Contact Email: _________________________________
PO Box 411, Wall, SD 57790 | 1-855-888-7777 | info@goldenwest.com | goldenwest.com