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Affordable Connectivity Program

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SW Texas - Customer Opt-In Form

Name:

Application ID:

Service Address:

City: State: Zip Code:

Mailing Address:

City: State: , Zip Code:

Home Phone: Mobile Phone:

Email:

Please list the qualifying assistance program (SNAP, low income, etc.):

If qualified with a child, please list full name & DOB:

I hereby opt in to the Affordable Connectivity Program (ACP). Initial to accept.

I understand that the ACP is a federal government subsidy that reduces my broadband internet access service bill, and that upon conclusion of the Program, my household will be subject to Southwest Texas Telephone Company, dba Southwest Texas Communication's {SWTC} undiscounted general rates, terms and conditions and normal monthly service charges will be restored if I choose to continue subscribing to the service from SWTC.

I understand that I may obtain broadband internet access service from any participating provider of my choosing, and that I may transfer my ACP program benefit to another provider at any time, but at this time, I consent to applying my ACP program benefit to the broadband internet access service I receive from SWTC.

I certiy that I:

(1) have confirmed my eligibility for the Affordable Connectivity Program through the National Verifier; or
(2) meet the eligibility standards as a current federal lifeline program beneficiary recipient.

I consent to SWTC 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 Connectivity Program benefit per household, from one participating provider, and I certify that no other member of my household is receiving an Affordable Connectivity Program 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 in order to qualify for the Tribal Affordable Connectivity Program , my residential address must be verified as located on Tribal lands.

I understand that the Affordable Connectivity Program amount will be issued as a monthly discount on my broadband internet access service, and that the benefit amount will not exceed SWTC's standard rate for my broadband internet access service.

I understand that due to the nature of this program, the Affordable Connectivity Program will not be prorated for a partial month of service, and may be less than the full benefit during the final month of the program when program funding is nearing depletion.

I understand that as a condition of receiving the Affordable Connectivity Program, I must use the broadband internet access 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 SWTC verifying my household's broadband usage each month to enable SWTC to claim reimbursement for my program benefit each month.

I understand that if SWTC has a reasonable basis to believe that I am no longer eligible to receive the ACP benefit, 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 SWTC 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 broadband 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 SWTC posted Rates, Terms and Conditions, filed Tariffs, Acceptable Use Policy or other rules and regulations that govern the services I receive.

Please scroll to the bottom and sign.

__________________________________________________________

For Official Use - SW Texas will complete the questions below. (DO NOT FILL THESE QUESTIONS OUT.)

SW Texas will complete the below questions when they receive the application.

Process Date:

Employee Name:

Customer eligibility confirmed in National Verifier? No Yes

If Yes, note benefit amount. ($30 for non Tribal, $75 for Tribal residents)If no, was the customer informed about eligibility status and provided instructions for completing eligibility step? No Yes

Customer information queried in National Lifeline Accountability Database? No Yes

Is customer currently receiving ACP benefit from another provider? No Yes

If yes, is customer seeking to transfer ACP benefit to SWTC No Yes

If yes, transfer request initiated in NLAD? NoYes

If no, SWTC cannot proceed with intiating ACP benefit for subscriber and must notify the customer accordingly. Confirm notification method and date/time: Is anyone else living in the prospective subscriber's address and receiving the ACP benefit? NoYes

If yes, customer must complete a form certifying compliance with the one-per-household rule prior to initial enrollment in the program. Attach form. Customer informatin entered into the National Lifeline Accountability Database? NoYes

If No, indicate reason why. Customer established in billing system with ACP billing codes? NoYes

If no, indicate reason why.

NOTE: this record and any related documentation of eligibility must be maintained for a minimum of 6 years after the last date the above-named customer received ACP program benefits.

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December 23, 2021 9:19 am CDT

Affordable Connectivity Program Uploaded by SW Texas Communications - crichmond@ltbx.net IP 24.130.90.157

December 23, 2021 10:16 am CDT