FCC FORM 5645
Aordable Connectivity Program
Application Form
Page 1 of 8
Rules
If you qualify, your household can receive a monthly Aordable Connectivity Program (ACP) benefit of up to
$30 to cover the cost of your internet service and up to $75 for qualifying households on Tribal lands.
Through the program, your internet company may also oer a one-time internet connected device benefit of
up to $100 for a computer, tablet, or laptop with a co-payment of more than $10 but less than $50.
Your household cannot get the ACP benefit from more than one company. You are only allowed to get one
ACP benefit per household, not per person.
The Aordable Connectivity Program is separate from the FCC’s Lifeline Program. If your household
qualifies for both programs, you can apply for and receive both benefits.
Note: Internet companies must also meet certain criteria to participate in the ACP. Check with your
c
ompany to determine if it participates.
What is a household?
A household is a group of people who live together and share income and expenses (even if they are not
related to each other). Complete the ACP household worksheet to determine if more than one qualifying
household is located at your address. If more than one person in your household participates in the ACP,
you are breaking the FCC’s rules and will lose your benefit.
Do not give your benefit to another person
The ACP benefit is non-transferable. You cannot give your benefit to another person, even if they qualify for
the ACP.
Be honest on this form
You must give accurate and true information on this form and on all ACP related forms or questionnaires. If
you give false or fraudulent information, you will lose your benefit (i.e., de-enrollment or being barred from
the program) and the United States government can take legal action against you. This may include (but is
not limited to) fines or imprisonment.
You may need to show other documents
If the ACP Administrator is not able to validate that you or someone in your household qualify by checking
available electronic resources (including eligibility databases for the FCC’s government agency partners),
you may need to provide additional documents. For example, you may need to provide an oicial
document that proves your participation in a qualifying government assistance program, your income, or
your identity. Please include copies of your proof documentation when you submit your application to
speed up processing time.
Apply
To apply for the ACP, fill out the required sections
of this form, initial every agreement statement,
and sign on page 7. You can also apply online at
AordableConnectivity.gov for fastest processing.
Mail the form to this address:
USAC
ACP Support Center
P.O. Box 9100
Wilkes-Barre, PA 18773
About
the ACP
The ACP
is a Federal
Communications
Commission (FCC)
program that
provides a monthly
internet service
discount and a
one-time connected
device benefit
from participating
internet companies
for qualifying low-
income consumers.
Universal Service Administrative Company | www.AffordableConnectivity.gov
Need help? Call the ACP Support Center at
1-877-384-2575
FCC FORM 5645
Aordable Connectivity Program
Application Form
Page 2 of 8
1. What is your full legal name?
The name you use on oicial documents, like your Social Security Card or State ID. Not a nickname.
2. What is your phone number (if you have one)?
First
Your
Information
All fields are required
unless indicated. Use only
CAPITALIZED LETTERS
and black ink to fill out
this form.
3. What is your date of birth?
Month Day Year
4. What is your email address? (Recommended)
5. Identity Verification. Please select one of the following:
a. If you would like to verify your identity using your Social Security number, please enter the
last four digits of your Social Security number (SSN4)*
Middle (optional) Suix (optional)
Last
*Social Security numbers are not required to participate in the Aordable Connectivity
Program, but providing a Social Security number will process your application the fastest.
b. If you have and would like to use a Tribal Identification number to verify your identity,
please enter it below.
c . Driver’s License, Military ID, Passport, Taxpayer Id
entification Number (ITIN), or other
Government ID. Please select the type of identification you would like to use to verify your identity.
Driver’s License
Military ID
Passport
Taxpayer Identification Number
Other Government ID
Please include a scanned copy or photo of your form of identification with your application.
Universal Service Administrative Company | www.AffordableConnectivity.gov
Need help? Call the ACP Support Center at 1-877-384-2575
FCC FORM 5645
Aordable Connectivity Program
Application Form
Page 3 of 8
Your
Information
(continued)
* Tribal lands include any federally
recognized Indian tribe’s reservation,
Pueblo, or colony, including former
reservations in Oklahoma; Alaska
Native regions established pursuant
to the Alaska Native Claims
Settlement Act (85 Stat. 688) ; Indian
allotments; Hawaiian Home Lands—
areas held in trust for Native
Hawaiians by the state of Hawaii,
pursuant
to the Hawaiian Homes Commission
Act, 1920 July 9, 1921, 42 Stat. 108,
et. seq., as amended; and any land
designated as such by the FCC
pursuant to the designation process
in the FCC’s Lifeline rules.
A map of qualifying Tribal lands is
available) on USAC’s website:
https://
www.affordableconnectivity.gov/wp-
content/uploads/acp/ documents/
fcc_tribal_lands_map.pdf
6. What is your home address? (The address where you will get service. Do not use a P.O. Box)
Street Number and Name
City
Zip Code
State
Apt., Unit, etc.
7. Is this a temporary address? Yes No 8. Check if you live on Tribal lands*
9. What is your mailing address? (Only fill this out if it is not the same as your home address.)
Street Number and Name
City
Zip Code
State
Apt., Unit, etc.
Universal Service Administrative Company | www.AffordableConnectivity.gov
Need help? Call the ACP Support Center at 1-877
-384-2575
FCC FORM 5645
Aordable Connectivity Program
Application Form
Page 4 of 8
Your
Information
(continued)
10. Check if you are qualifying through a child or dependent in your household.
If so, answer the following questions:
11. What is their full legal name?
Only fill this section
out if you are
applying through a
child or dependent.
First
12. What is their date of birth?
Month Day Year
Middle (optional) Suix (optional)
Last
13. Identity Verification. Please select one of the following:
a. If you would like to verify your identity using your Social Security number, please enter the
last four digits of your Social Security number (SSN)*
*Social Security numbers are not required to participate in the Aordable Connectivity
Program, but providing a Social Security number will process your application the fastest.
b. If you have and would like to use a Tribal Identification number to verify your identity
please enter it below.
c . Driver’s License, Military ID, Passport, Taxpayer Identification Number (ITIN), or other
Government ID. Please select the type of identification you would like to use to verify your identity.
Driver’s License
Military ID
Passport
Taxpayer Identification Number
Other Government ID
Please include a scanned copy or photo of your form of identification with your application.
Universal Service Administrative Company | www.AffordableConnectivity.gov
Need help? Call the ACP Support Center at
1-877-384-2575
FCC FORM 5645
Aordable Connectivity Program
Application Form
Page 5 of 8
Qualify for
the ACP
Fill out this section to
show that you, your
dependent, or someone in
your household qualifies
for the ACP.
You can qualify through
certain government
assistance programs or
through your income (you
do not need to qualify
through both).
When you mail this form,
please include documents
that show you participate
in one of the programs
you selected or that you
qualify through your
income. A list of acceptable
documents is available at
AordableConnectivity.gov.
Qualify through a government program:
Or
14. Check all programs that you or someone in your household have:
Supplemental Nutrition Assistance Program (SNAP, also called Food Stamps)
Supplemental Security Income (SSI)
Medicaid
Federal Public Housing Assistance (FPHA)
Housing Choice Voucher (HCV) Program (Section 8 Vouchers)
Project-Based Rental Assistance (PBRA)/202/811
Public Housing
Aordable Housing Programs for American Indians, Alaska Natives or Native Hawaiians
Veterans Pension or Survivors Benefit Programs
Federal Pell Grant for the current award year
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Free and Reduced-Price School Lunch or Breakfast Program, or enrollment in a Community
Eligibility Provision School. If you choose this program, please enter your school name, school
district and state.
School Name School District State
Tribal Specific Programs
Bureau of Indian Aairs (BIA) General Assistance
Tribal Temporary Assistance for Needy Families (Tribal TANF)
Food Distribution Program on Indian Reservations (FDPIR)
Tribal Head Start (only households that meet the income qualifying standard)
Universal Service Administrative Company | www.AffordableConnectivity.gov
Need help? Call the
ACP Support Center at 1-877-384-2575
FCC FORM 5645
Aordable Connectivity Program
Application Form
Page 6 of 8
Qualify for
the ACP
(continued)
Qualify through your income:
15. Including you, how
many people live in your
household?
(check one)
16. Is your income the same or less than the amount listed for
your state and household size?
(only check yes or no next to your household size)
All 48 States, DC,
and Territories
Alaska Hawaii
1
$29,160 $36,420 $33,540
Yes No
2
$39,440 $49,280 $45,360
Yes No
3
$49,720 $62,140 $57,180
Yes No
4
$60,000 $75,000 $69,000
Yes No
5
$70,280 $87,860 $80,820
Yes No
6
$80,560 $100,720 $92,640
Yes No
7
$90,840 $113,580 $104,460
Yes No
8
$101,120 $126,440 $116,280
Yes No
If more than 8, add this
amount for each extra person:
Add $10,280 Add $12,860 Add $11,820
Yes No
200% of the 2023 Federal Poverty Guidelines
*The Federal Poverty Guidelines are typically updated at the end of January.
Universal Service Administrative Company | www.AffordableConnectivity.gov
Need help? Call the ACP Support Center at
1-877-384-2575
FCC FORM 5645
Aordable Connectivity Program
Application Form
Page 7 of 8
27. Signature 28. Today’s Date
Agreement
I agree, under
penalty of perjury,
to the following
statements:
You must initial next to
each statement. If you
fail to initial each
statement, your
application will be
considered incomplete.
By providing a phone number,
you consent to letting USAC
contact you at that phone
number via artificial or
prerecorded voice message or
text for important reminders and
updates about your ACP benefit.
For text messages, message and
data rates may apply.
Text STOP to end messages.
Initial
17. I (or my dependent or other person in my household) currently get benefits from the
government program(s) listed on this form or my annual household income is 200% or less
than the Federal Poverty Guidelines (the amount listed in the Federal Poverty Guidelines
table on this form).
Initial
18. I agree that if I move I will give my service provider my new address within 30 days.
Initial
19. I understand that I have to tell my service provider within 30 days if I do not qualify for the
ACP anymore, including:
1) I, or the person in my household that qualifies, do not qualify through a
government program or income anymore.
2) Either I or someone in my household gets more than one ACP benefit.
Initial
20. I know that my household can only get one ACP benefit and, to the best of my knowledge,
my household is not getting more than one ACP benefit. I understand that I can only receive one
connected device (desktop, laptop, or tablet) through the ACP, even if I switch ACP companies.
Initial
21. I agree that all of the 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 Program Administrator, I will not be able to get ACP benefits.
If the laws of my state or Tribal government require it, I agree that the state or Tribal government
may share information about my benefits for a qualifying program with the ACP Administrator.
The information shared by the state or Tribal government will be used only to help find out if I can
get an ACP benefit.
Initial
22. For my household, I airm and understand that the ACP is a federal government subsidy
that reduces my broadband internet access service bill and at the conclusion of the program, my
household will be subject to the company’s undiscounted general rates, terms, and conditions if
my household continues to subscribe to the service.
Initial
23. All the answers and agreements that I provided on this form are true and correct to the best
of my knowledge.
Initial
24. I know that willingly giving false or fraudulent information to get ACP benefits is punishable
by law and can result in fines, jail time, de-enrollment, or being barred from the program.
Initial
25. The ACP Administrator or my service provider may have to check whether I still qualify at any
time. If I need to recertify my ACP benefit, I understand that I have to respond by the deadline or I will
be removed from the Aordable Connectivity Program and my ACP benefit will stop.
The certification below applies to all consumers and is required to process your application.
Initial
26. I was truthful about whether or not I am a resident of Tribal lands, as defined in the “Your
Information” section of this form.
Universal Service Administrative Company | www.AffordableConnectivity.gov
Need help? Call the
ACP Support Center at 1-877-384-2575
FCC FORM 5645
Aordable Connectivity Program
Application Form
Page 8 of 8
Representative
Information
Representatives who help
consumers apply (such as
internet company agents,
state and Tribal partners,
etc.) are required to register
in the Representative
Accountability Database
(RAD) and must enter their
Representative ID here.
29. What is your Representative ID?
How Does the ACP Protect Consumers?
The rules protect Aordable Connectivity Program recipients by:
• Empowering consumers to choose the service plan that best meets their needs (including a plan they may already be on);
• Ensuring consumers have access to supported internet services regardless of their credit status;
• Prohibiting companies from excluding consumers with past due balances or prior debt from enrolling in the program;
• Preventing consumers from being forced into more expensive or lower quality plans in order to receive the ACP;
• Reducing the potential for bill shock or other financial harms;
• Allowing ACP recipients to switch companies or internet service oerings; and
• Providing a dedicated FCC process for ACP complaints at https://consumercomplaints.fcc.gov.
Privacy Act Statement
This Privacy Act Statement explains how we are going to use the personal information you are entering into this form.
The Privacy Act is a law that requires the Federal Communications Commission (FCC) and the Universal Service Administrative
Company (USAC) to explain why we are asking individuals for personal information and what we are going to do with this
information aer we collect it.
Authority: 47 U.S.C. §254; 47 U.S.C. §1752; 47 CFR Part 54, Subparts E and R.
Purpose: We are collecting this personal information so we can verify your identity and that you qualify for the Lifeline program
or similar programs that use income or consumer participation in certain government benefit programs as eligibility criteria, such
as the Aordable Connectivity Program. We access, maintain and use your personal information in the manner described in the
Lifeline System of Records Notice (SORN), FCC/WCB-1, and the Aordable Connectivity Program SORN, formerly known as the
Emergency Broadband Benefit Program SORN, FCC/WCB-3, both available at https://www.fcc.gov/managing-director/privacy-
transparency/ privacy-act-information#systems/.
Routine Uses: We may share the personal information you enter into this form with other parties for specific purposes, such as:
• With contractors that help us operate the Lifeline program and similar programs that use income or consumer participation
in certain government benefit programs as eligibility criteria, such as the Affordable Connectivity Program;
• With other federal and state government agencies and Tribal agencies that help us determine your Lifeline eligibility and
eligibility for similar programs that use income or consumer participation in certain government benefit programs as
eligibility criteria, such as the Affordable Connectivity Program;
• With the telecommunications companies and broadband providers that provide you Lifeline service and service under a
similar program that uses income or consumer participation in certain federal benefit programs as eligibility criteria, such as
the Affordable Connectivity Program;
• With other federal agencies or to other administrative or adjudicative bodies before which the FCC is authorized to appear;
• With appropriate agencies, entities, and persons when the FCC suspects or has confirmed that there has been a breach of
information; and
• With law enforcement and other officials investigating potential violations of Lifeline and other program rules.
A complete listing of the ways we may use your information is published in the Lifeline SORN and the Aordable Connectivity
Program SORN (formerly known as the Emergency Broadband Benefit Program SORN) described in the “Purpose” paragraph of
this statement.
Disclosure: You are not required to provide the information we are requesting, but if you do not, you will not be eligible to receive
Lifeline services under the Lifeline Program rules, 47 C.F.R. Part 54, Subpart E, or benefits under the Aordable Connectivity
Program rules, 47 C.F.R. Part 54, Subpart R.
Universal Service Administrative Company | www.AffordableConnectivity.gov
Need help? Call the
ACP Support Center at 1-877-384-2575