Affordable Connectivity Program Form

Please complete and submit the form in order to apply for the monthly internet service discount with Voonami. For additional information regarding this program, visit https://www.affordableconnectivity.gov.

Your Name(Required)

First Last

ACP Application ID(Required)

Your Phone Number(Required)

Your Email Address(Required)

Email Address Confirm Email Address

Date of Birth (mm/dd/yyyy)(Required)

Last 4 of SSN(Required)

Your Physical Address(Required)

Street Address Address Line 2 City State ZIP Code

Are you the Benefit Qualifying Person?(Required)

Yes

Name of Benefit Qualifying Person (BQP)(Required)

First Last

BQP's Date of Birth (mm/dd/yyyy)(Required)

BQP's Last 4 of SSN(Required)

Please agree to ALL of the following conditions in order to apply for the Affordable Connectivity Program discount:

I acknowledge and confirm that checking the boxes below constitutes my acknowledgement and understanding of the outlined terms. By checking the boxes outlined in this form, I agree to all the conditions in order to apply for the Affordable Connectivity Program.(Required)

This is a United States government program that reduces my internet bill.(Required)

This is a United States government program that reduces my internet bill.

This program is limited to one per household. I know that my household can only receive one Affordable Connectivity Program benefit, and, to the best of my knowledge, my household is not receiving more than one Affordable Connectivity Program benefit.(Required)

I/ or the person in my household who qualifies, currently receives benefits from the government program(s) listed on this form or their annual income is 200% less than the federal poverty guidelines.(Required)

I/ or the person in my household who qualifies, currently receives benefits from the government program(s) listed on this form or their annual income is 200% less than the federal poverty guidelines.

I understand that I must notify my service provider within 30 days of no longer being qualified for the Affordable Connectivity Program benefit, including: I, or the person in my household that qualifies, no longer qualify through a government program or income no longer qualifies. Either I, or someone in my household, gets more than one ACP benefit.(Required)

I understand that I must notify my service provider within 30 days of no longer being qualified for the Affordable Connectivity Program benefit, including:
• I, or the person in my household that qualifies, no longer qualify through a government program or income no longer qualifies.
• Either I, or someone in my household, gets more than one ACP benefit.

I allow Voonami, Inc. to transmit my information to the National Lifeline Accountability Database to enroll into the Affordable Connectivity Program.(Required)

I allow Voonami, Inc. to transmit my information to the National Lifeline Accountability Database to enroll into the Affordable Connectivity Program.

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 if this information is not provided to the Program Administrator, I will not be able to get ACP benefits. If the laws of my state or Tribal government require it, I agree that the state or Tribal government may share information about my benefits for a qualifying program with the ACP Administrator. The information shared by the state or Tribal government will be used only to help find out if I can get an Affordable Connectivity Program benefit.(Required)

All the answers and agreements that I provided on this form are correct and true to the best of my knowledge.(Required)

All the answers and agreements that I provided on this form are correct and true to the best of my knowledge.

I acknowledge that willingly giving false or fraudulent information to get Affordable Connectivity Program benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program.(Required)

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Affordable Connectivity Program Form

Please agree to ALL of the following conditions in order to apply for the Affordable Connectivity Program discount:

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