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Affordable Connectivity Program (ACP) | Form 5645 online | CAATCRCC
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Eligibility Programs
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Demographics
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Last 4 digits of your SSN
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phone
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Benefit Qualifying Person (BQP): Check if you are qualifying through a child or dependent in your household. Once checked please enter the child/dependent details.
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Please check all the following Disclosures:
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I hereby certify that I have read and understood the disclosures listed above regarding activation and usage requirements.
I authorize SWA Connect and its contracted partners, for the purpose of applying for, determining eligibility, enrolling in and seeking reimbursement of Affordable Connectivity Program service and device benefits, to collect, use, share and retain my personal information, including but not limited to information required for the purpose of establishing eligibility for and enrolling in the ACP, and including, but not limited to, full name, full residential address, date of birth, last four digits of social security number, telephone number, eligibility criteria and status, the date on which the ACP service discount was initiated and if applicable, terminated, ACP connected device distribution date/ type/make and model/status, usage status and other compliance requirements, the amount of support being sought for the service and/or device, and information necessary to establish identity and verifiable address, to the Universal Service Administrative Company (USAC) to ensure proper administration of the ACP service and/ or connected device benefits. Failure to provide consent will result in me being denied the Emergency Broadband Benefit service and/ or the connected device benefits.
I agree that any state, local, Tribal government, school or school district, may share information about my receipt of benefits that would establish eligibility for the ACP, and that such information will be used only to determine ACP eligibility.
I give express consent for SWA Connect and its contracted partners to contact me to validate my eligibility for or desire to participate in SWA Connect's ACP offers, and other products and services via email, telephone, or text messaging. Text messaging and data rates may apply. Consent for calls and texts is optional and can be revoked at any time. For more information see our Terms and Conditions and Privacy Policy at www.swaconnect.com.
I understand that the Affordable Connectivity Program connected device discount is limited to one per household. If I received a connected device discount with SWA Connect as part of the ACP program, I certify that I was charged $11.00 for the connected device. Additionally, I certify that to the best of my knowledge that no one in my household has received a connected device discount with the Affordable Connectivity Program.
I understand I have the right to enroll in the ACP service using non-electronic methods. I further understand that I have the right to withdraw this consent at any time prior to activation of my service. The Company has advised me that I may request a paper copy of my contract and associated fees by calling 1-866-350-0222.
I hereby authorize SWA CONNECT to send me notifications, via text messages, emails, and phone calls (by automated telephone dialing system, manually, or with pre-recorded/ artificial voice messages) regarding my ACP benefit, marketing messages, and promotional offers. I may withdraw my consent to receive some of these messages by calling 1-866-350-0222. Opting out will not affect the Company's ability to contact me with messages regarding the ACP program and/ or service functionality via the methods listed herein.
I acknowledge that I am providing the information I have included in this application to SWA CONNECT, LLC and further authorize SWA CONNECT, LLC to receive and use my information for enrollment verification and waste, fraud and abuse mitigation purposes. Additionally, I authorize SWA CONNECT, LLC to receive and use my historic ACP enrollment information for enrollment verification and waste, fraud and abuse mitigation purposes.
I agree that my service provider can give the ACP Program administrator all of the information I am giving on this form. I understand that this information is meant to help run the ACP Program and that if I do not let them give it to the Administrator; I will not be able to get ACP benefits.
ACP program participants are eligible to participate in the new federal government funded Affordable Connectivity Program (ACP). The SWA Connect FREE ACP plan includes up to 10 GB of 5G/4G High Speed Data. To Opt-IN to this ACP plan, please read the following and OPT-IN below. The ACP is a program operated by the Federal Communications Commission (FCC) that provides discounts on monthly broadband Internet access service and certain connected devices. The ACP monthly service and device discounts are non-transferrable. An eligible household is limited to one monthly service discount and one device discount. ACP Program benefits may be obtained from any participating provider of your choosing and your monthly service benefit may be transferred to another provider at any time.
If/when the FCC announces the end of the ACP program or we end our promotional FREE ACP service offer, we will notify you and you will revert to receiving only the standard FREE ACP plan where available and if you are eligible. You may keep your ACP service by paying the applicable undiscounted rate of $40.00 plus fees and taxes. Our standard terms and conditions apply.
I understand that ACP benefits are limited to one per household. If I am found to already be receiving an ACP discount benefit from another provider, I understand my current benefit will be transferred to SWA Connect. I consent to the transfer of my ACP discount benefit from my current ACP provider to SWA Connect. For more information about ACP eligibility, specifics on SWA Connect's ACP plan including upload/ download speeds, and general information on the program call us at 1-866-350-0222 or visit www.swaconnect.com.
I hereby certify that I have read and understood the disclosures
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