ACP Opt-in Agreement

AFFORDABLE CONNECTIVITY PROGRAM (ACP) DISCLOSURES AND OPT-IN AGREEMENT

NOTE: Red asterisks * indicate required fields.

* Name:

* Contact Phone Number:

* Date of Birth (mm-dd-yyyy):

* Last Four Digits of Social Security Number:

* ACP Program ID Number:

* Address:

* City:

* State:

* Zip:

Mailing Address (if different):

Mailing City:

Mailing State:

Mailing Zip:

If you qualified through a dependent in your household, provide

Their Name:

Their Date of Birth (mm-dd-yyyy):

Their Last Four Digits of Social Security Number:

ACP Program ID Number:

I understand the following, (please initial each statement in the box)

* Affordable Connectivity Program (ACP) is a federal government benefit program operated by the Federal Communications Commission that provides a discount up to $30 on my monthly Internet service bill.

* Households are eligible to participate in ACP by meeting one of the following criteria: (1) household income is at or below 200% of the Federal Poverty Guidelines, (2) participating in assistance programs such as Lifeline, SNAP, Medicaid, Federal Public Housing Assistance, SSI, WIC, the National School Lunch or Breakfast Program, including through the USDA Community Eligibility Provision, or (3) receipt of a Federal Pell Grant during the current award year.

* Only one monthly Internet service discount is allowed per household. A household is defined as anyone living at the same address who share income and household expenses. This program is non-transferable to any other individual or household.

* I may choose to participate in the ACP from any participating service provider and I may transfer the ACP benefit to another provider at any time during this program.

* I authorize Ayersville Communications to disclose and transmit my information to the Universal Service Administrative Company and the National Lifeline Accountability Database to verify and enroll my household in the ACP program. Information this applies to may include but not be limited to my name, my dependent’s name, date of birth, last four digits of social security number or Tribal identification number, address, telephone number, type of service, start date of service, and termination date.

* I understand if I cannot demonstrate eligibility, I will not be enrolled or may be de-enrolled if a I am no longer eligible.

* I may apply the ACP benefit of any Internet service offering of Ayersville Communications at the same general terms and conditions available to households that are not eligible for the same ACP supported service.

* I understand the ACP will not be prorated for a partial month of service or enrollment and may be less than the full benefit during the final month of the program when program funding is depleted.

* I understand my ACP eligible Internet service may be disconnected after 90 consecutive days of non-payment.

* I will be subject to the Ayersville Communications undiscounted rates and general terms and conditions if Affordable Connectivity Program ends, or if I transfer my ACP benefit but continue to receive service from Ayersville Communications or upon de-enrollment from the ACP.

* I may file a complaint against Ayersville Communications via the FCC’s Consumer Complaint Center.

* I will notify Ayersville Communications if I no longer choose to continue Ayersville Communications Internet service.

By initialing all lines above and signing this form, I confirm that I have reviewed the above disclosures about the ACP, consent to apply my ACP program benefit to my Internet service from Ayersville Communications and that all the above is true and complete to the best of my knowledge.

* Signature (type your complete legal name):

* Date of Signature (mm-dd-yyyy):

Any questions, call 419-395-2222 or email info@ayersvilletelco.com
This form must be initialed, signed and submitted before Ayersville Communications can apply the ACP program benefit to your Internet service.

Your form has been successfully submitted.
Please contact our Billing Department at 419-395-2222 to complete the opt-in process.
Thank you