Disclosure of Affordable Connectivity Benefits Transfer Disclosure of Affordable Connectivity Benefit Transfer Paragraph I hereby consent and authorize the transfer of my Affordable Connectivity Program (ACP) benefits to ATC Communications (transfer-in provider) from my previous Internet Service Provider (transfer-out provider): • I acknowledge that my ACP benefit discount will transfer to ATC Communications (transfer-in provider). • I acknowledge that my ACP benefit will be applied to ATC Communications (transfer-in provider’s) service and will no longer be applied to service retained from the transfer-out provider. • I acknowledge I may be subject to the transfer-out provider’s undiscounted rates as a result of the transfer if I elect to maintain service from the transfer-out provider. • I acknowledge that I am limited to one ACP benefit transfer transaction per service month, with limited exceptions for situations where I seek to reverse the unwanted transfer or am unable to receive service from a specific provider. * I have read and agree to the terms and conditions listed above Full Name * Your ATC Account Number * Service Location Address * Mailing Address * Home Phone Number (use cellphone if you don't subscriber to phone service from ATC) * Date your ACP application was approved * Email Address * Last 4 of Social Security # * Date of Birth (mm/dd/yy) * Qualifying Application ID # * In some cases, an application may have been submitted under a name/person OTHER than the one listed above. Please list the benefit-qualifying person's (BQP) info below? Full Name Date of Birth (mm/dd/yy) Last 4 of Social Security # Please upload your approval letter from USAC or email a copy to cnye@atccomm.com Drop a file here or click to upload Choose File Maximum file size: 516MB Please check the box below to confirm your understanding that: 1. You are enrolled in a government program that reduces your broadband Internet bill by $30 per month. 2. You may obtain broadband service supported by the ACP Program from any participating provider of your choosing. 3. You may transfer your ACP Program benefit to another provider at any time. 4. By submitting this form you agree to allow ATC Communications to submit this information to USAC to verify and confirm your eligibility. * I understand and agree Signature of ACP Subscriber * Clear Date Signed by ACP Subscriber * CAPTCHA If you are human, leave this field blank. Submit
