Affordable Connectivity Program Consent

Affordable Connectivity Program – Consent Form

Application Date*
MM slash DD slash YYYY
Account Number*

Please provide the account number that is on your current bill.
Last 4 digits of your Social Security Number*

Please provide the account number that is on your current bill.
WHAT IS YOUR AFFORDABLE CONNECTIVITY PROGRAM ID NUMBER?

Please provide the Affordable Connectivity Program (ACP) ID Number that was given to you when you enrolled.
Legal Name*
First Last Suffix
Subscriber Birth Date*
MM slash DD slash YYYY
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email
Subscriber Consent
AFFORDABLE CONNECTIVITY PROGRAM QUALIFICATION FORM. By signing this form, I give my affirmative consent that I want to participate in the Affordable Connectivity Program through Mosaic Technologies and that I understand and certify that:
ACP provides a discount of up to $30 per month depending on the price of the service tier or bundle. if the total bill exceeds $30 per month, I will be responsible for the remaining balance after the ACP discount is applied. this includes any taxes and required fees that are applied to the full amount of the service.*

Initial Here
I am either a current lifeline customer or my eligibility has been verified by the national verifier so that I qualify for the ACP. I am a current Affordable Connectivity subscriber, and it has been verified by the national verifier. I request to Transfer my ACP benefit to Mosaic Technologies. I understand I am limited to transferring my ACP benefit once per service month (which corresponds to calendar month).*

Initial Here
Due to the temporary nature of this program, the ACP monthly benefit may be less than the full benefit during the final month of the program when program funding is nearing depletion.*

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My existing lifeline discount, if it is currently being applied to internet service, will be applied to my bill first, then the ACP credit will be applied.*

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My household may obtain broadband service supported by the ACP from any participating provider of my choosing and I may transfer my ACP benefit to another provider at any time.*

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I may only receive one ACP benefit per household, from one participating provider, and I certify that no other member of my household is receiving an emergency broadband benefit under the ACP.*

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All official communications for ACP will be via electronic mail or text messaging and I consent to receive such communications from Mosaic Technologies.*

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I agree that all 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 that if this information is not provided to the ACP program administrator, I will not be able to get ACP benefits.*

Initial Here
Mosaic Technologies will notify me of the end date of the ACP and give me the opportunity to opt-in to continue receiving my broadband service plan to which I am subscribed under the ACP by paying the regular rates, terms, and conditions for the plan. If I do not opt-in, Mosaic Technologies will discontinue providing the broadband internet service plan I have been receiving under the program.*

Initial Here
When the affordable connectivity program (ACP) ends and I opt to keep my broadband service plan when the rates return to standard non-discounted rates, the rates, including fees, and taxes.*

Initial Here
Consent*
I agree
I consent to all fields/questions that are presented above.
Terms of Service Agreement*
I agree
I CONSENT to ALL Terms of Service agreement(s) that are associated with the Affordable Connectivity Program provided by Mosaic Legal
Signature*
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Name
This field is for validation purposes and should be left unchanged.

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Affordable Connectivity Program – Consent Form

Subscriber Consent

Headquarters

Find remote payment drop boxes at the below locations

BARRON

CHETEK

RICE LAKE

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