Foothills Communications Affordable Connectivity Program Enrollment Form

This signed Affordable Connectivity Program (ACP) Enrollment Form is required to enroll you in Foothills Communications' ACP
Program. The National Verifier, not Foothills Communications, determines your eligibility to receive ACP. Only persons who
have been determined to be eligible by the National Verifier, or are currently receiving the Lifeline discount through
Foothills Communications, should complete this Enrollment Form. If you do not currently receive the Lifeline discount and
have not qualified for ACP through the National Verifier, please visit www.affordableconnectivity.gov to apply.

The information you enter on this Enrollment Form must be exactly the same as what you provided to the National Verifier to receive eligibility approval,
which expires after 45 days. Submission of this form does not guarantee an immediate ACP discount with Foothills Communications

Are you currently receiving the Lifeline discount through Foothills Communications? (ONLY SELECT YES IF YOU ARE CURRENTLY RECEIVING LIFELINE BENEFITS)(Required)

Yes

National Verifier Application ID

Name(Required)

First

Name

Middle

Name(Required)

Last

Date of Birth(Required)

Last 4 digits of SSN(Required)

Foothills Communications Phone Number

Foothills Communications Account Number

Email(Required)

Enter Email Confirm Email

*email address is required - Foothills Communications will send all information regarding the ACP program by email

RESIDENTIAL ADDRESS

Must be a street address (not a P.O. Box) and your principle residence.

Street Address (911 Address)(Required)

Apt

City(Required)

State(Required)

Zip Code(Required)

Mailing Address

Apt

City

State

Untitled

Zip Code

QUALIFICATION THROUGH DEPENDENT

Complete if you qualified in the National Verifier through a child or dependent in your household.

First Name

Middle Initial

Last Name

Date of Birth

Last 4 Digits of Social Security Number

BENEFIT TRANSFER REQUEST (If applicable)

By transferring my ACP-support to Foothills Communication, I understand that the ACP benefit will be applied to my Foothills Communication ACP-supported broadband and will no longer be applied to any services that I may keep with my prior provider. My household may be subject to my prior provider’s undiscounted rates as a result of the transfer for any services that I may maintain with that prior provider. My household is limited to one ACP-transfer per month with limited exceptions to reverse an improper transfer or address situations impacting my household’s receipt of ACP-supported service from a particular provider.

I currently receive ACP benefits from another carrier, and I request that Foothills Communications submit a Benefit Transfer on my behalf on the date below.

CERTIFICATIONS

Affirmation1(Required)

I agree(Required)

I authorize government agencies and their authorized representatives to discuss with, receive from and provide information to Foothills Communications that is relevant to my eligibility to receive ACP benefits from Foothills Communications. I consent and give permission for Foothills Communications to transmit any of my personal information disclosed on this Enrollment Form to verify my eligibility with the Universal Service Administrative Company.

Affirmation2(Required)

I agree(Required)

I affirm that I understand the ACP Program is a temporary federal government subsidy that temporarily reduces my broadband internet access service bill and at the conclusion of the ACP Program, I will be subject to Foothills Communications' undiscounted general, rates, terms, and conditions if I continue to subscribe to the service.

Affirmation3(Required)

I agree(Required)

I hereby elect to continue to subscribe to the service upon the conclusion of the ACP Program and understand that I will remain subscribed to the service until such time as I affirmatively contact Foothills Communications and either (i) cancel my service or (ii) switch to an alternative, lower-priced broadband plan. I make this election with the understanding that in the final month of the ACP Program, the ACP discount may be reduced. If this box is not checked, Foothills Communications will stop providing Fibernet service to the household on the applicable service line at the conclusion of the ACP Program. Notwithstanding this election, I understand that I may contact Foothills Communications and cancel my service at any time.

Affirmation3(Required)

I agree(Required)

I understand that a new certification will be added to the ACP Application that a consumer must complete prior to submitting the application. This certification specifies that USAC or a consumer’s service provider may verify that the consumer still qualifies for the ACP benefit at any time.

Affordable Connectivity Program (ACP) Notices and Disclosures

By signing this form, I give my affirmative consent that I want to participate in the Affordable Connectivity Program through Foothills Communications and that I understand that the following terms apply:

* Affordable Connectivity Program (“ACP”) is a government program that reduces my broadband internet access service bill by up to $30 per month.
* My household may obtain ACP-supported broadband service from any participating provider of its choosing and I may transfer my ACP benefit to another provider at any time.
* My household may apply the ACP benefit to any broadband service offering of Foothills Communication at the same terms available to households that are not eligible for ACP-supported service. Unless otherwise stated herein, Foothills Communication broadband services are subject to the Foothills Communication Terms of Service found here.
* My broadband service will be subject to Foothills Communication’S undiscounted rates and general terms and conditions if the program ends, if I transfer my benefit to another provider but continue to receive service from Foothills Communication, or upon de-enrollment from the Affordable Connectivity Program.
* My broadband shall not be subject to early termination fees if I choose to terminate or modify my broadband service during my participation in the ACP or upon receiving notice of the benefit ending.
* My household is limited to one ACP benefit and should any other member of my household receive an ACP benefit, my household may be subject to de-enrollment from the Affordable Connectivity Program.
* Foothills Communication may disconnect my ACP-supported broadband service after 90 consecutive days of non-payment. Services other than ACP-supported broadband may be disconnected for non-payment according to Foothills Communication’s normal processes.
* Information I provide to Foothills Communication may be collected, used, shared, and retained for the purposes of compliance with the ACP Program.
* Ongoing eligibility in the ACP program is subject to annual reverification.
* My household may file a complaint against its provider via the Commission’s Consumer Complaint Center at (877) 384-2575.

APPLICANT SIGNATURE

By my electronic signature below, I certify that the information provided above is true and correct, and agree to the above Certifications. I further certify that I have read and understand the above Notices and Disclosures of this Enrollment Form.

Name(Required)

First Last

Date(Required)

CAPTCHA

*You may file complaint against your provider via the FCC Consumer Complaint Center - Click here for more information