ACP form | United & Turtle Mountain Communications

Affordable Connectivity Program

To sign up for the Affordable Connectivity Program (ACP), follow the steps below. Please note you must first apply with, and receive approval from, the FCC before United & Turtle Mountain Communications can offer you these benefits.

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Step 1 of 2

Step One:

Apply for the Affordable Connectivity Program with the FCC through the Lifeline National Verifier here.

Important: Please note that to receive the benefits of this program, you must first apply with, and receive approval from, the FCC. Without this approval, we will not be able to offer you the ACP benefits.

Select one:*

Yes, I have received approval from the FCC to receive ACP benefits.

No, I have not received approval from the FCC to receive ACP benefits.

Whoops!

You must first apply with, and receive approval from, the FCC to receive the ACP benefits. Please apply with the FCC through the Lifeline National Verifier here first. Once you've received approval, come back to this page to complete your application with United & Turtle Mountain Communications.

Step Two:

After you’ve been approved by the FCC to receive your ACP benefits, please complete and submit the following form.

Important: to avoid being denied the benefit, both forms (Lifeline National Verifier application and this form) must contain identical information (name, address, abbreviations, middle name or middle initial, etc.). For example, if you spell out ‘Avenue’ on one but use ‘Ave’ on the other, your application will be denied.

Consent 1*

I have received approval for the Affordable Connectivity Program Benefit through the Lifeline National Verifier.*

Consent 2*

I agree that all the information I provide on this form may be collected, used, shared, and retained for the purposes of receiving the Affordable Connectivity Program (ACP) benefit. I understand that this information will be transmitted to the ACP Program Administrator and, if this information is not provided to the ACP Program Administrator, I will not be able to receive ACP benefits. If required by the laws of my state or Tribal government, I agree that the state or Tribal government may share information about my benefits for a qualifying program with the ACP Program Administrator. The information shared by the state or Tribal government will be used only to help determine if I am eligible for the ACP Program benefit.*

Consent 3*

I affirm that I am eligible to receive the ACP Program benefit and request that United & Turtle Mountain Communications apply this benefit to my broadband Internet access service.*

Consent to Transmit Subscriber Information to the National Lifeline Accountability Database*

I give my consent to United Communications/Turtle Mountain Communications to transmit to the federal National Lifeline Accountability Database (a federal database which is also being used for proper administration of the ACP) all subscriber information that I submit in applying for the monthly ACP discount benefit, including, but not limited to, the following: subscriber’s full name; full residential address; date of birth; telephone number associated with ACP service; date the ACP discount was initiated; date the ACP discount is terminated, if it has been terminated; amount of support being sought for subscriber; and the means through which subscriber qualified for the ACP. I understand that failure to provide this consent will result in a denial of the Affordable Connectivity Program benefit.

Affordable Connectivity Program (ACP) Consent*

I hereby provide my written consent that United Communications/Turtle Mountain Communications can enroll me in the Affordable Connectivity Program (ACP).

I am qualified for (select one):*

ACP Only

Lifeline and ACP

I understand the ACP is a government program that 1) began on December 31, 2021, 2) reduces my broadband internet access bill and 3) is temporary. The program may end once the funds are exhausted. 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 United Communications/Turtle Mountain Communications. United Communications/Turtle Mountain Communications may disconnect my ACP supported service after 90 consecutive days of non-payment of any past due charges associated with the supported service (calculated from the due date of the past due bill or invoice). The ACP 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 on the amount higher than what I would pay if the full ACP benefit were applied to my broadband bill. I understand that I may obtain ACP support from any ACP participant and I can transfer my Affordable Connectivity Program benefit to another ACP participant at any time. I also understand that I am not able to transfer to another ACP participant more than once a month. The ACP provides only one monthly discount on broadband service per household and a one-time benefit for an eligible connected device, if applicable. Continued participation in the ACP benefit requires that I remain eligible under the designated qualifying assistance programs or income threshold criteria. Continued participation is also subject to annual recertification to be conducted by the Universal Service Administrative Company (USAC). The Federal Communications Commission (FCC) has made available a dedicated complaint process to address subscriber issues concerning ACP enrollment or participating provider provisioning of ACP-supported services. The FCC’s Consumer Complaint Center for ACP can be found at: https://consumercomplaints.fcc.gov/hc/en-us*

I understand the following:*

I understand the ACP is a government program that 1) began on December 31, 2021, 2) reduces my broadband internet access bill and 3) is temporary. The program may end once the funds are exhausted. 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 United Communications/Turtle Mountain Communications.
United Communications/Turtle Mountain Communications may disconnect my ACP supported service after 90 consecutive days of non-payment of any past due charges associated with the supported service (calculated from the due date of the past due bill or invoice).

The ACP 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 on the amount higher than what I would pay if the full ACP benefit were applied to my broadband bill.

I understand that I may obtain ACP support from any ACP participant and I can transfer my Affordable Connectivity Program benefit to another ACP participant at any time. I also understand that I am not able to transfer to another ACP participant more than once a month.

The ACP provides only one monthly discount on broadband service per household and a one-time benefit for an eligible connected device, if applicable. Continued participation in the ACP benefit requires that I remain eligible under the designated qualifying assistance programs or income threshold criteria. Continued participation is also subject to annual recertification to be conducted by the Universal Service Administrative Company (USAC).

The Federal Communications Commission (FCC) has made available a dedicated complaint process to address subscriber issues concerning ACP enrollment or participating provider provisioning of ACP-supported services. The FCC’s Consumer Complaint Center for ACP can be found at: https://consumercomplaints.fcc.gov/hc/en-us

Please consider your service options after the ACP has ended and indicate your choice:*

I wish to continue my broadband service with United Communications/Turtle Mountain Communications after the ACP has ended.

I do not wish to continue my broadband service with United Communications/Turtle Mountain Communications after the ACP has ended.

Please read and initial each statement below to confirm you have read and understand the disclosures related to the Affordable Connectivity Program.

Consent 7b*

I agree that if I move, or if I become ineligible for the ACP, I will notify UC/TMC within 30 days.*

Consent 8*

I understand that the ACP benefit is limited to one discount per household and affirm that, to the best of my knowledge, my household is not receiving more than one ACP benefit.*

Consent 9*

I agree that all 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 this information will be transmitted to the ACP Administrator and, if this information is not provided to the ACP Administrator, I will not be able to receive ACP benefits.*

Consent 10*

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.*

I have received approval from the ACP Administrator.

My application ID number is:

Signature*

By signing below, I acknowledge that I have received and understand the disclosures regarding the Affordable Connectivity Program (ACP). I affirm that I am eligible to receive the ACP benefit and request that UC/TMC enroll me in the ACP and apply this benefit to my Internet service.

Date*

Name*

First Last

Date of Birth*

Last 4 of SSN*

Dependent’s Name:*

First Last

Dependent's Date of Birth*

Dependent's Last 4 of SSN*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Account Number*

Email*

CAPTCHA

*To receive the benefits of this program, you must first apply with, and receive approval from, the FCC through the Lifeline National Verifier. Without this approval, United & Turtle Mountain Communications will not be able to offer you the ACP benefits.

Step One:

Whoops!

You must first apply with, and receive approval from, the FCC to receive the ACP benefits. Please apply with the FCC through the Lifeline National Verifier here first. Once you've received approval, come back to this page to complete your application with United & Turtle Mountain Communications.

Step Two:

Please read and initial each statement below to confirm you have read and understand the disclosures related to the Affordable Connectivity Program.

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