Affordable Connectivity Program Customer Opt-In Form Date MM slash DD slash YYYY Name* First Last Application ID* Last 4 of SS NumberDate of Birth MM slash DD slash YYYY Address* Physical Address City State ZIP Contact Phone*Preferred Email* I certify that I have either:* confirmed my eligibility for the Affordable Connectivity Program through the National Verifier; or meet the eligibility standards as a current federal Lifeline program beneficiary recipient. Select one.Benefit Qualifying Person (Child/Dependent) InformationIf your eligibility for the Affordable Connectivity Program through the National Verifier was based on a Benefit Qualifying Person (Child/Person), we will need the following information for the individual used for eligibility in the program. Ex. Student's Info based on Free & Reduced Lunch ProgramQualifying Person (Child/Dependent) Name First Last Qualifying Person (Child/Dependent) Date of Birth MM slash DD slash YYYY Qualifying Person (Child/Dependent) Last 4 of SS NumberAcknowledgmentsBelow you will find ACP requirements, rules and/or restrictions. Read and acknowledge all applicable statements below. Failure to fully accept all program statements may result in disqualification from ACP participation. Acknowledge each program requirement, rule, and/or restriction.* I hereby opt in to the Affordable Connectivity Program (ACP). I understand that I may obtain internet service from any participating provider of my choosing and that I may transfer my ACP benefit to another provider at any time, but at this time, I consent to applying my ACP program benefit to the internet service I receive from Peoples. I consent to Peoples transmitting all information required for program participation to the program Administrator to ensure the proper administration of the Affordable Connectivity Program. This information may include my or my eligible dependent’s name, mailing and primary address, date of birth, telephone number, ACP discount amount, eligible program, tribal benefit status, service type, service initiation date, service termination date, last 4 digits of social security number or Tribal Identification Number, Lifeline Tribal Benefit, Linkup Service Date and Independent Economic Household certification date. I understand that I may only receive one Affordable Connectify Program benefit per household, from one participating provider, and I certify that no other member of my household is receiving a broadband benefit under the ACP. I understand that if I share an address with one or more existing ACP subscribers according to the National Lifeline Accountability Database or National Verifier, I must complete a form certifying compliance with the one-per-household rule prior to initial enrollment in the program. I understand that the ACP benefit amount will be issued as a monthly credit on my internet service, and that the benefit amount will not exceed Peoples’ standard rate for my internet service. I understand that as a condition of receiving the ACP benefit, I must use the internet service at least once during the service month, and that failure to do so will result in loss of the program benefit for that month. I consent to Peoples verifying my household’s broadband usage each month to enable Peoples to claim reimbursement for my program benefit each month. I understand that if Peoples has a reasonable basis to believe that I am no longer eligible to receive the ACP benefit, I will receive a notification of impending termination of my ACP benefit, and will have 30 days following the date of such notice to demonstrate continued eligibility. I understand that if I cannot demonstrate eligibility, I will not be enrolled in the program and/or Peoples is required to de-enroll me from the program. I understand that I will not be required to pay early termination fees if I choose to terminate or modify my internet service during my participation in the ACP, or upon receiving notice of the benefit ending. I understand that unless otherwise stated herein, my participation in the ACP does not alleviate my obligations to adhere to Peoples’ posted Rates, Terms and Conditions, filed Tariffs, Acceptable Use Policy or other rules and regulations that govern the services I receive. I understand that failure to pay ACP supported services within 30 days can result in a downgrade of speed/package. I understand that failure to pay ACP supported services within 90 days will result in termination of service and de-enrollment from the program. Failure to fully accept all statements may result in ACP program disqualification. SignatureSignature Acknowledgment* I acknowledge that by digitally signing this form, I am responsible for the information herein.Digital Signature* Please type your name.
