ACP Customer Enrollment/Transfer-In Consent Form

Information of Qualifying Person
Please provide the information of the individual that qualified for the Affordable Connectivity Program (ACP) as it was entered at the FCC’s Qualify for ACP website to determine eligibility. This may be different than the WCTEL/WCFIBER/UPCOUNTRY FIBER’s account holder.
By signing this form, I acknowledge and give my affirmative consent that I want to participate in the Affordable Connectivity Program through WCTEL/WCFIBER/UPCOUNTRY FIBER and that I understand and certify that: • Affordable Connectivity Program (“ACP”) is a government program operated by the Federal Communications Commission (FCC) that reduces the customer’s broadband internet access service bill. • I may obtain ACP-supported broadband service from any participating provider of my choosing and I may transfer my ACP benefit to another provider at any time. • I may choose to take ACP benefits from a service provider other than my existing Lifeline provider. • I am either a current Lifeline customer or my eligibility has been verified by the National Verifier so that I qualify for the ACP. I may continue my Lifeline service if I choose not to enroll in the ACP. • ACP provides a discount of up to a $30 per month toward broadband service for eligible households. I will be responsible for the remaining balance after the ACP discount is applied. This includes any taxes and required fees that are applied to the full amount of the service. • WCTEL/WCFIBER/UPCOUNTRY FIBER may disconnect my household’s ACP-supported service after 90 consecutive days of non-payment. • I have been made aware of all ACP-supported plans available in the household’s service area that are fully covered by the ACP benefit. • I may only receive one ACP benefit per household, from one participating provider, and I certify that no other member of my household is receiving a benefit under the ACP. • My household may apply the benefit to any broadband service offering at the same terms available to households that are not eligible for ACP supported service. • My existing Lifeline discount, if it is currently being applied to internet service, will be applied to my bill first, then the ACP credit will be applied. • All official communications for ACP will be via email and I consent to receive such communications from WCTEL/WCFIBER/UPCOUNTRY FIBER. • My household will be subject to WCTEL/WCFIBER/UPCOUNTRY FIBER’s undiscounted rates and general terms and conditions if the ACP ends, if I choose to transfer out my ACP benefit to another provider but continue to receive service from WCTEL/WCFIBER/UPCOUNTRY FIBER, or upon my de-enrollment. • My household may file a complaint against WCTEL/WCFIBER/UPCOUNTRY FIBER via the FCC’s Consumer Complaint Center. • I agree that all information I provide on this form and any service enrollment form may be collected, used, shared, and retained for the purposes of applying for and/or receiving the ACP benefit. I understand that if this information is not provided to the ACP Program Administrator, then I will not be able to get ACP benefits. • I understand that I have to tell my service provider within 30 days if I no longer qualify for ACP. • My service provider or Program Administrator may have to check whether I still qualify at any time. If I need to recertify (renew) my ACP benefit, I understand that I have to respond by the deadline or I will be removed from ACP and my ACP benefit will stop. • All the answers and agreements that I provided on this form are true and correct to the best of my knowledge. • 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.(Required)

Additional disclosures for transfers-in only. If you are not transferring in your ACP credit you can continue on to submit form.
Additional disclosures for transfers-in: I give my affirmative consent to transfer my ACP benefit to WCTEL/WCFIBER/UPCOUNTRY FIBER and agree and certify that: • I understand my ACP benefit will be applied to my new service and will no longer be applied to service retained from the transfer-out provider. • I may be subject to the transfer-out provider’s undiscounted rates as a result of the transfer if I elect to maintain service from the transfer-out provider. • I am aware of the one ACP benefit transfer transaction per service month.