Lifeline Program

Please complete the form below after you've submitted your application HERE and have been approved.

DO NOT PROCEED UNLESS YOUR APPLICATION HAS ALREADY BEEN APPROVED AND YOU HAVE RECEIVED AN APPROVAL ID NUMBER.

The information below MUST BE IDENTICAL to the data you submitted to the Universal Service Administrative Co. (USAC).

Lifeline

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 Lifeline 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

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 $9.25 per month.

2. You may obtain broadband service supported by the Lifeline Program from any participating provider of your choosing.

3. You may transfer your Lifeline Program benefit to another provider at any time.

4. By submitting this form you agree to allow ATC Communications to submit this information to NLAD to verify and confirm your eligibility.

I understand and agree

Consent Date

Consent Time

If you are human, leave this field blank.

Lifeline Program

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