ACP Consent Form

Please enter the exact information you submitted to the National Verifier. Any differences (such as nicknames, titles, misspellings, etc.) may cause your application to be rejected.

First *

Last *

Street Address *

City *

State: * - Select a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code *

Phone Number *

Email *

National Verifier Application ID *

Date of Birth *

Last four digits of Social Security Number #, if you did not use your social security # to qualify, please enter 0000 *

If the benefit-qualifying person is not the person listed above, complete the below certification. (Examples include: child of an above-named individual is enrolled in National School Lunch Program [NSLP] or School Breakfast Program [SBP]; the above-named individual is named power of attorney for qualifying participant; qualifying participant is disabled but resides in the same household as the above-named individual.)

Did you qualify for the program because of a dependent? *

• Yes
• No

First

Last

Dependent Date of Birth

Last four digits of Dependent's Social Security #last four digits of Dependent's Social Security #

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The Affordable Connectivity Program (ACP) and Lifeline are government programs adopted by the Federal Communications Commission (FCC) to reduce the cost of your broadband internet access service bill by application of the ACP benefit to your bill. Your household must meet and maintain its eligibility criteria to participate in ACP. We may request additional information concerning your eligibility status at any time. You may be de-enrolled from the programs and no longer receive the ACP discount if you no longer meet ACP eligibility criteria.

ACP is a program created by the federal government, and as such, will be available so long as it is funded and the program remains authorized. If the program is discontinued and you choose to continue to receive internet access service from Midwest Energy & Communications (MEC), you will be subject to our undiscounted rates and general terms and conditions of service applicable to your services. MEC will inform you if the programs are scheduled to end and when any undiscounted rates will be applied to your account. You are responsible for payment of the portion of your internet access service billed to you that is not covered by the ACP discount. MEC will notify you and may disconnect your ACP-supported service after 90 consecutive days of non-payment of amounts billed and due.

The information you are providing may be considered sensitive personal information. While privacy laws give you the right to limit how we use or disclose such data, we are required by other laws to keep and store the information for certain periods of time. 

Assuming you are eligible, you are able to obtain ACP benefits from any participating provider you choose; however, you cannot receive the ACP benefit from more than a single provider at a time. For more information about the Affordable Connectivity Program, visit www.affordableconnectivity.gov. Also, the FCC maintains a consumer complaint process specifically for issues with ACP that can be accessed at the FCC Helpline at 877-384-2575 or at consumercomplaints.fcc.gov/hc/en-us.

Any eligible household may apply the ACP benefit to any broadband service offering of MEC on the same terms available to households not eligible for ACP benefits.

If you are transferring your ACP benefit to MEC from another provider, the following terms also apply. Should an eligible household seek to transfer its ACP benefit to MEC, the effect of the transfer is that your ACP benefit will be applied to your MEC service billing, and once transferred, will no longer be applied to any service retained from the transferred-from provider. You may be subject to the transferred-from provider’s undiscounted rates even after the ACP benefit transfer to MEC if you elect to maintain other services from that provider. The eligible household is limited to one ACP benefit transfer transaction per service month, with limited exceptions for situations where the subscriber seeks to reverse an unwanted transfer or is unable to receive service from a specific provider.

Check here to indicate that you have read the disclosures above and agree to terms of the Affordable Connectivity Program and to terms and conditions of MEC's ACP Consent Form and the terms of service. *