FCC FORM 5645

Affordable Connectivity Program

Application Form

About Rules
the ACP
If you qualify, your household can receive a monthly Affordable Connectivity Program (ACP) benefit of up
to $30 to cover the cost of your internet service (up to $75 on qualifying Tribal lands). Through the
program, your service provider may also offer a one-time internet connected device benefit of up to $100
for a computer, tablet, or laptop with a co-payment of more than $10 but less than $50.

Your household cannot get the ACP benefit from more than one service provider. You are only allowed to
The ACP get one ACP benefit per household, not per person. If more than one person in your household
is a Federal participates in the ACP, you are breaking the FCC’s rules and will lose your benefit.
Communications
The Affordable Connectivity Program is separate from the FCC's Lifeline Program. If your household
Commission qualifies for both programs, you can apply for and receive both benefits.
(FCC) program that
provides a broadband Note: Broadband service providers must also meet certain criteria to participate in the ACP. Check with
your service provider to determine if it participates.
and/or one-time
connected device
benefit for qualifying What is a household?
low-income A household is a group of people who live together and share income and expenses (even if they are not
consumers. related to each other).

Do not give your benefit to another person

The ACP benefit is non-transferable. You cannot give your benefit to another person, even if they qualify for
the ACP.

Be honest on this form

You must give accurate and true information on this form and on all ACP related forms or questionnaires. If
you give false or fraudulent information, you will lose your benefit (i.e., de-enrollment or being barred from
the program) and the United States government can take legal action against you. This may include (but is
not limited to) fines or imprisonment.

You may need to show other documents

If the ACP Administrator is not able to validate that you or someone in your household qualify by checking
available electronic resources (including eligibility databases for the FCC's government agency partners),
you may need to provide additional documents. For example, you may need to provide an official
document that proves your participation in a qualifying government assistance program, your income, or
your identity.

Apply Mail the form to this address:

USAC
To apply for the ACP, fill out the required sections of this form,
initial every agreement statement, and sign on page 7. You can Affordable Connectivity Support Center
also apply online at ACPbenefit.org for faster processing. P.O. Box 7081
London, KY 40742

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FCC FORM 5645
Affordable Connectivity Program
Application Form
-·
1 1 If■ Universal Service
Ii■■ Administrative Co.

Your What is your full legal name?

Information
The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

All fields are required First

unless indicated. Use only
CAPITALIZED LETTERS
and black ink to fill out Middle (Optional) Suffix (optional)
this form.

Last

2. What is your phone number (if you have one)? 3. What is your date of birth?

Month Day Year

4. What is your email address? (Recommended)

5. Identity Verification. Please select one of the following:

a. If you would like to verify your identity using your Social Security number, please enter the
last four digits of your Social Security number (SSN4)*

*Social Security numbers are not required to participate in the Affordable Connectivity
Program, but using a Social Security number will process your application the fastest.
b. If you have and would like to use a Tribal Identification Number to verify your identity,
please enter it below.

c. Driver’s License, Military ID, Passport, Taxpayer Identification Number (ITIN), or other
Government ID. Please select the type of identification you would like to use to verify your identity.

Driver’s License
Military ID
Passport
Taxpayer Identification Number
Other Government ID

Please include a scanned copy or photo of your form of identification with your application.

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Affordable Connectivity Program
Application Form
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1 1 If■ Universal Service
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Your 6. What is your home address? (The address where you will get service. Do not use a P.O. Box.)

Information
(continued) Street Number and Name

Apt., Unit, etc. City

eStat Zip Code

* Tribal lands include any 7. Is this a temporary address? Yes No 8. Check if you live on Tribal lands*
federally recognized Indian
tribe’s reservation, Pueblo, or 9. What is your mailing address? (Only fill this out if it is not the same as your home address.)
colony, including former
reservations in Oklahoma;
Alaska Native regions Street Number and Name
established pursuant to the
Alaska Native Claims
Settlement Act (85 Stat. 688) ;
Apt., Unit, etc. City
Indian allotments; Hawaiian
Home Lands—areas held in
trust for Native Hawaiians by
the state of Hawaii, pursuant State Zip Code
to the Hawaiian Homes
Commission Act, 1920 July 9,
1921, 42 Stat. 108, et. seq., as
amended; and any land
designated as such by the FCC
pursuant to the designation
process in the FCC’s Lifeline
rules.
A map of qualifying Tribal
lands is available on USAC's
website: https://
www.usac.org/wp-content/
uploads/lifeline/documents/
tribal/
fcc_tribal_lands_map.pdf.

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Affordable Connectivity Program
Application Form
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Your 10. Check if you are qualifying through a child or dependent in your household. If

Information so, answer the following questions:

11. What is their full legal name?

(continued)
First
Only fill this section
out if you are
applying through a
Middle (optional) Suffix (optional)
child or dependent.

Last

12. What is their date of birth?

Month Day Year

13. Identity Verification. Please select one of the following:

a. If you would like to verify their identity using their Social Security number, please enter the
last four digits of their Social Security number (SSN4)*

*Social Security numbers are not required to participate in the Affordable Connectivity
Program, but using a Social Security number will process your application the fastest.

b. If you have and would like to use a Tribal Identification Number to verify their identity,
please enter it below.

c. Driver’s License, Military ID, Passport, Taxpayer Identification Number (ITIN), or other
Government ID. Please select the type of identification you would like to use to verify their identity.

Driver’s License
Military ID
Passport
Taxpayer Identification Number
Other Government ID

Please include a scanned copy or photo of their form of identification with your application.

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FCC FORM 5645
Affordable Connectivity Program
Application Form
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1 1 If■ Universal Service
Ii■■ Administrative Co.

Qualify for Qualify through a government program:

the ACP 14. Check all programs that you or someone in your household have:
Supplemental Nutrition Assistance Program (SNAP, also called Food Stamps)
Fill out this section to
Supplemental Security Income (SSI)
show that you, your
dependent, or someone Medicaid
in your household Federal Public Housing Assistance (FPHA)
qualifies for the ACP. Veterans Pension or Survivors Benefit Programs
Federal Pell Grant for the current award year
You can qualify through Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
certain government Free and Reduced Price School Lunch or Breakfast Program, or enrollment in a
assistance programs or Community Eligibility Provision School for the 2019-20, 2020-21, or 2021-22 school year. If
through your income (you you choose this program, please enter your school name, school district and state.
do not need to qualify School Name School District State
through both).

Tribal Specific Programs

When you mail this form,
please include Bureau of Indian Affairs (BIA) General Assistance
documents that show Tribal Temporary Assistance for Needy Families (Tribal TANF)
you participate in one of Food Distribution Program on Indian Reservations (FDPIR)
the programs you
Tribal Head Start (only households that meet the income qualifying standard)
selected or that you
qualify through your
income. A list of
acceptable documents is Or
available at
ACPbenefit.org.

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FCC FORM 5645
Affordable Connectivity Program
Application Form
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1 1 If■ Universal Service
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Qualify for Qualify through your income:

the ACP 15. Including you, how 16.Is your income the same or less than the amount listed for

(continued) I many people live in your

household? (check one)
your state and household size?
(only check yes or no next to your household size)
All 48 States, DC,
and Territories Alaska Hawaii
I
1 $25,760 $32,180 $29,640 Yes No

2 $34,840 $43,540 $40,080 Yes No

3 $43,920 $54,900 $50,520 Yes No

4 $53,000 $66,260 $60,960 Yes No

5 $62,080 $77,620 $71,400 Yes No

6 $71,160 $88,980 $81,840 Yes No

7 $80,240 $100,340 $92,280 Yes No

8 $89,320 $111,700 $102,720 Yes No

If more than 8, add this
Add $9,080 Add $11,360 Add $10,440 Yes No
amount for each extra person:

200% of the 2021 Federal Poverty Guidelines

*The Federal Poverty Guidelines are typically updated at the end of January.

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FCC FORM 5645
Affordable Connectivity Program
Application Form

Agreement Initial
17. I (or my dependent or other person in my household) currently get benefits from the
government program(s) listed on this form or my annual household income is 200% or less
than the Federal Poverty Guidelines (the amount listed in the Federal Poverty Guidelines
I agree, under table on this form).
penalty of perjury,
to the following 18. I agree that if I move I will give my service provider my new address within 30 days.
statements:
Initial

You must initial next to

19. I understand that I have to tell my service provider within 30 days if I do not qualify for
each statement. If you the ACP anymore, including:
fail to initial each Initial 1.) I, or the person in my household that qualifies, do not qualify through a
statement, your government program or income anymore.
application will be 2.) Either I or someone in my household gets more than one ACP benefit.
considered incomplete.
20. I know that my household can only get one ACP benefit and, to the best of my
knowledge, my household is not getting more than one ACP benefit. I understand that I can
Initial only receive one connected device (desktop, laptop, or tablet) through the ACP, even if I
switch ACP providers.

21. I agree that all of 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
Initial 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 ACP benefit.

22. For my household, I affirm and understand that the ACP is a federal government subsidy
that reduces my broadband internet access service bill and at the conclusion of the
Initial program, my household will be subject to the provider’s undiscounted general rates, terms,
and conditions if my household continues to subscribe to the service.

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

24. I know that willingly giving false or fraudulent information to get ACP benefits is
punishable by law and can result in fines, jail time, de-enrollment, or being barred from the
Initial program.

25. I was truthful about whether or not I am a resident of Tribal lands, as defined in the
"Your Information" section of this form.
Initial

26. Signature 27. Today's Date

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FCC FORM 5645
Affordable Connectivity Program
Application Form
-·
1 1 If■ Universal Service
Ii■■ Administrative Co.

Representative 28. What is your Representative ID?

Information
Answer only if a Service
Provider Representative
submits this form.

Privacy Act Statement

This Privacy Act Statement explains how we are going to use the personal information you are entering into this form.
The Privacy Act is a law that requires the Federal Communications Commission (FCC) and the Universal Service Administrative
Company (USAC) to explain why we are asking individuals for personal information and what we are going to do with this
information after we collect it.
Authority: 47 U.S.C. §254; Consolidated Appropriations Act, 2021, Public Law 116–260, div. N, tit. IX, § 904, as modified by the
Infrastructure Investment and Jobs Act, Public Law 117-58, div. F, tit. V, secs. 60501, 60502(a)-(b); 47 CFR Part 54, Subparts E and P.
Purpose: We are collecting this personal information so we can verify your identity and that you qualify for the Lifeline program or
similar programs that use income or consumer participation in certain government benefit programs as eligibility criteria, such as
the Affordable Connectivity Program. We access, maintain and use your personal information in the manner described in the Lifeline
System of Records Notice (SORN), FCC/WCB-1, and the Affordable Connectivity Program SORN, formerly known as the Emergency
Broadband Benefit Program SORN, FCC/WCB-3, both available at https://www.fcc.gov/managing-director/privacy-transparency/
privacy-act-information#systems/.
Routine Uses: We may share the personal information you enter into this form with other parties for specific purposes, such as:

• With contractors that help us operate the Lifeline program and similar programs that use income or consumer participation
in certain government benefit programs as eligibility criteria, such as the Affordable Connectivity Program;
• With other federal and state government agencies and Tribal agencies that help us determine your Lifeline eligibility and
eligibility for similar programs that use income or consumer participation in certain government benefit programs as
eligibility criteria, such as the Affordable Connectivity Program;
• With the telecommunications companies and broadband providers that provide you Lifeline service and service under a
similar program that uses income or consumer participation in certain federal benefit programs as eligibility criteria, such as
the Affordable Connectivity Program;
• With other federal agencies or to other administrative or adjudicative bodies before which the FCC is authorized to appear;
• With appropriate agencies, entities, and persons when the FCC suspects or has confirmed that there has been a breach of
information; and
• With law enforcement and other officials investigating potential violations of Lifeline and other program rules.

A complete listing of the ways we may use your information is published in the Lifeline SORN and the Affordable Connectivity
Program SORN (formerly known as the Emergency Broadband Benefit Program SORN) described in the
"Purpose" paragraph of this statement.
Disclosure: You are not required to provide the information we are requesting, but if you do not, you will not be eligible to
receive Lifeline services under the Lifeline Program rules, 47 C.F.R. Part 54, Subpart E, or benefits under the Affordable
Connectivity Program rules, 47 C.F.R. Part 54, Subpart P.

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