1. What is your full legal name?

The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

2. Your Phone Number?

3. Your Date Of Birth?

4. Your Email

5. Identity Confirmation. Please select one of the following:



(b) What is your Tribal ID? I do not have a Social Security Number and was enrolled with my Tribal ID.

6. What is your home address? (The address where you will get service. Do not use a P.O. Box.)

7. Do you live on Tribal lands ?

8. Check all programs that you or someone in your household have:

9. Upload document of government assistance you are receiving.

10. I (or my dependent or another person in my household) currently receive benefits from the government program(s) listed on this form, or my annual household income is 200% or less than the Federal Poverty Guidelines.

11. I agree to notify my internet company of my new address within 30 days if I move.

12. I hereby grant permission to IJ Wireless, Inc. to reinstate my services using the current MDN (Mobile Directory Number) and the Talk, Text, and Data package previously agreed upon.

13. I understand that I must inform my internet company within 30 days if I no longer qualify for the ACP, which includes:

a. The person in my household no longer qualifies through a government program or income.

b. Either I or someone in my household receives more than one ACP benefit.

14. I acknowledge that my household is only eligible for one ACP benefit, and to the best of my knowledge, my household is not receiving multiple ACP benefits. I also understand that I can only receive one connected device (desktop, laptop, or tablet) through the ACP, even if I switch ACP companies.

15. I agree that all the information provided 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 failure to provide this information to the Program Administrator will result in the denial of ACP benefits. If required by the laws of my state or Tribal government, I consent to the sharing of information about my benefits for a qualifying program with the ACP Administrator. This shared information will solely be used to determine my eligibility for an ACP benefit.

16. I affirm and understand that the ACP is a federal government subsidy that reduces my broadband internet access service bill. At the conclusion of the program, my household will be subject to the company's regular rates, terms, and conditions if we continue to subscribe to the service.

17. I confirm that all the answers and agreements provided on this form are true and correct to the best of my knowledge.

18. I understand that providing false or fraudulent information to obtain ACP benefits is illegal and can result in fines, imprisonment, de-enrollment, or being barred from the program.

19. Please indicate the appropriate statement if any of the exceptions below apply to your household:

Leave this empty:

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Signature Certificate
Document name: bot
lock iconUnique Document ID: fdf7c5f9c8a7c84d7f5b33ecdc7fedfcda90ae49
Timestamp Audit
05/02/2024 4:56 pm -06bot Uploaded by IJ Wireless - IP 2407:d000:d:fe03:c404:17c5:646d:ff1d