Affordable Connectivity Program Form
ACP Form With Consent
Acknowledgment and Consent for Enrollment
Before enrolling a household in the Affordable Connectivity Program (ACP), Public Service is required to make the following disclosures and obtain your consent to enroll.
- The Affordable Connectivity Program (ACP) is a government program that reduces the customer’s internet access service bill.
- The household may obtain Affordable Connectivity Program-supported internet service from any participating provider of its choosing.
- The household may apply the affordable connectivity benefit to any internet service offering of the participating provider at the same terms available to households that are not eligible for Affordable Connectivity Program-supported service.
- The provider may disconnect the household’s Affordable Connectivity Program-supported service after 90 consecutive days of non-payment.
- The provider is required to remove the ACP discount for non-usage based on FCC’s required measurement of usage during a rolling 30 days.
- The household will be subject to the provider’s undiscounted rates and general terms and conditions if the Affordable Connectivity Program should end, if the customer transfers their benefit to another provider but continues to receive service from the current provider, or upon de-enrollment from the Affordable Connectivity Program
- The household may file a complaint against its provider via the Commission’s Consumer Complaint Center at Phone Number: 1-888-225-5322, Video phone number: 1-844-432-2275 or Website address: https://consumercomplaints.fcc.gov/hc/en-us
- You acknowledge that you were provided the disclosure language required under the ACP rules; and indicate that having received the required disclosures, that you are giving your informed consent to enroll your ACP benefit with Public Service.
Affordable Connectivity Program (ACP) Consent Form
The form below must be filled out and returned to Public Service for your credits to be applied to your service. The information must match EXACTLY what was submitted and approved by the National Verifier to prevent delays in your CP or Lifeline credits being applied to your account.
DO NOT SUBMIT UNTIL AFTER YOU HAVE RECEIVED YOUR APPLICATION ID APPROVAL FROM THE NATIONAL VERIFIER TO BE SUBMITTED WITH THIS FORM.