SWTexas ACP Part II

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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.

ACP Applicants Name:  

Process Date:

Employee Name:  

Customer eligibility confirmed in National Verifier?

 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?

 Customer information queried in National Lifeline Accountability Database?

Is customer currently receiving ACP benefit from another provider?
  If yes, is customer seeking to transfer ACP benefit to SWTC
If yes, transfer request initiated in NLAD?
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?
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?
If No, indicate reason why. Customer established in billing system with ACP billing codes?
 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.

Leave this empty:

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Signature Certificate
Document name: SWTexas ACP Part II
lock iconUnique Document ID: 66283787de94654b7576d23f7dfbf89286aa4032
Timestamp Audit
May 19, 2023 9:49 am CDTSWTexas ACP Part II Uploaded by SW Texas Communications - crichmond@ltbx.net IP
May 19, 2023 3:09 pm CDTACP SW Texas Team - acp@swtexas.com added by SW Texas Communications - crichmond@ltbx.net as a CC'd Recipient Ip: