ACP Sign Up

You are likely eligible if your household’s income is below 200% of the Federal Poverty Line or you (or someone in your household) participate in one of these programs:

* Medicaid

* SNAP

* WIC

* SSI

* Free and Reduced-Price School Lunch Program

* Federal Public Housing Assistance

* Received a Federal Pell Grant in the current award year

First Name/Nombre *

Last Name/Apellido *

Date of Birth (DOB) / Fecha de Nacimiento *

Please enter your date of birth/Por favor, introduzca su fecha de nacimiento.

Preferred Language/Idioma *

Last 4 digits of social/Los cuatro ultimos digitos de su social *

Street address/direccion de su hogar *

Apartment, Unit, etc.

City/Ciudad *

Zip Code/Codigo de Zip *

Sex/sexo masculino o femenino *

Male

Female

Race/Raza *

Black or African American

Hispanic

Asian

White

Other

Prefer not to say

Email address/Correo electronico *

Phone number/numero de telefono *

How do you qualify?/Cuales programas

tiene?

SNAP

Medicaid

WIC

SSI

Federal Public Housing Assistance

Veterans Pension and Survivors Benefit

Free or reduced lunch

Federal Pell Grant in the current award year

Income

Read the 10 following statements provided by the Federal Communications Commission (FCC) which supports the ACP. After reading please check yes or no if you can agree with the following statements. * 1\. I \(or my dependent\) receive the programs I listed above

2\. If I move I will give my internet company my new address within 30 days

3\. If I no longer receive the government program\(s\) I listed\, I will tell my internet company

4\. I know that my household can only receive 1 ACP benefit

5\. The information provided can be collected\, used\, shared\, and retained by the FCC

6\. I know that the ACP is a federal government subsidy and at the program’s conclusion my rate will go back to what it was before

7\. All the answers provided are truthful

8\. I know that willingly giving false information to get ACP benefits is punishable by law

9\. I know that the ACP administrator may have to check whether I qualify occasionally

10\. The address I used is accurate\.

Do you consent to receiving ACP sign up navigation from the Link Health team? *

Link Health Data Collection

Link Health Data Collection

Link Health Data Collection