qualify

Affordable Connectivity Program (ACP) | Form 5645 online

Please select the program you are currently enrolled in

Eligibility Programs (*)

Federal Public Housing Assistance (FPHA)

Free & Reduced-Price School Lunch Program or School Breakfast Program

Medicaid

Supplemental Nutrition Assistance Program (SNAP/Food Stamps)

Supplemental Security Income (SSI)

Veterans Pension and Survivors Benefit Programs

Qualify through my Income

Federal Pell Grant for the current award year

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Demographics

First Name(*)

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Middle Name

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Last Name(*)

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Second Last Name

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Date Of Birth

Date of Birth(*)

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Last 4 digits of your SSN(*)

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What is the best way to reach you(*)

EmailPhoneText MessageMail Invalid Input

phone(*)

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Email(*)

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Address(*)

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Apt/Floor/Other

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City(*)

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State(*)

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Zip Code(*)

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My Residential Address is(*)

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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.

YesNo Invalid Input

First Name (dependent)(*)

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Date of Birth (dependent)(*)

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Middle Name (dependent)

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Last 4 digits of dependent SSN(*)

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Last Name (dependent)(*)

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Second Last Name (dependent)

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Device Copay Payment

The Affordable Connectivity Program (ACP) allows qualifying subscribers to claim a one time discount toward a tablet.

The FCC requires us to charge a copay amount.

Our Copay for an Android Tablet with 4G LTE Connectivity is a one-time $11.00

(A transaction of $11.00 will be drafted when the prospect subscriber is approved to receive a Tablet)

Credit Card Number(*)

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CVV Code(*)

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Exp. Date(*)

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First Name on Credit Card(*)

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Last Name on Credit Card(*)

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Address on credit card(*)

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City on credit Card(*)

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State on credit card(*)

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Zip code on credit card(*)

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Do I Qualify for ACP?

Affordable Connectivity Program (ACP) | Form 5645 online

The Affordable Connectivity Program (ACP) allows qualifying subscribers to claim a one time discount toward a tablet.

The FCC requires us to charge a copay amount.

Our Copay for an Android Tablet with 4G LTE Connectivity is a one-time $11.00