ACP form | United & Turtle Mountain Communications

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.*

Disclosures and Customer Consent to Transfer

Please read and initial each statement below to confirm you have read and understand the disclosures related to the transfer of your Affordable Connectivity Program benefit to United & Turtle Mountain Communications (UC/TMC):

Consent 4*

I acknowledge that my Affordable Connectivity Program (ACP) benefit will be transferred to UC/TMC.*

Consent 5*

I understand that my ACP benefit will be applied to service from UC/TMC and will no longer be applied to service retained from my previous provider.*

Consent 6*

I understand that, as a result of transferring my ACP benefit to UC/TMC, I may be subject to my previous provider’s undiscounted rates if I choose to retain service from that provider.*

Consent 7*

I understand that I am limited to one ACP benefit transfer per service month, with limited exceptions where a subscriber seeks to reverse an unwanted transfer or is unable to receive service from a specific provider.*

Consent 8*

I acknowledge that I have received the disclosures related to my request to transfer my Affordable Connectivity Program (ACP) benefit. I understand these disclosures and I consent to the transfer of my ACP benefit to United & Turtle Mountain Communications.*

I qualify for the ACP Program:*

select one

By myself

Through a dependent

My eligibility requirement is:*

Name of Dependent and School*

Disclosures and Consent to Enroll

The Affordable Connectivity Program (ACP) is a federal government program that provides a monthly discount on broadband service for qualifying low-income households. If you qualify, your household can receive a monthly ACP benefit of up to $30 toward the cost of your Internet service. If you live on qualifying Tribal lands, you may receive a discount of up to $75.

If you are currently enrolled in the FCC’s Lifeline program, you are eligible to participate in the Affordable Connectivity Program and do not have to submit a separate application to determine your eligibility for the ACP. The ACP is separate from the FCC’s Lifeline Program. If your household qualifies for both programs, you can apply for and receive both benefits. You may continue your existing Lifeline service without enrolling in the ACP.

Your household cannot receive the ACP benefit from more than one service provider. You are only allowed one ACP benefit per household, not per person. If more than one person in your household participates in the ACP, you are breaking the Federal Communication Commission’s rules and will lose your benefit.

You may choose to receive your ACP benefits from any broadband Internet access service provider participating in the ACP, and you may transfer your ACP benefits to another service provider at any time.

You may choose to apply your ACP benefit to any internet service offering that is currently available at your address at the same terms available to households that are not eligible for the ACP.

If you no longer qualify for the ACP benefit (such as your income exceeds the income level or you no longer participate in a qualifying benefits program), you must notify UC/TMC or the ACP administrator within 30 days.

You will be subject to UC/TMC’s undiscounted rates, terms and conditions if the Affordable Connectivity Program ends, if you transfer your ACP benefit to another service provider but continue to receive service from UC/TMC, or if you are de-enrolled from the ACP.

UC/TMC may disconnect your ACP-supported service after 90 consecutive days of non-payment. This 90-day period begins the first day the bill for your ACP-supported service becomes delinquent and subject to late fees.

You may file a complaint against UC/TMC via the Federal Communication Commission’s Complaint Center.

By signing below, I acknowledge that I have read and understand the disclosures regarding the Affordable Connectivity Program.

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:

Disclosures and Customer Consent to Transfer

Disclosures and Consent to Enroll

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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