Sign Up for the Affordable Connectivity Program - Kayenta Technologies

In order to apply and determine your eligibility for the monthly discount on your broadband service, please complete the following questions and then press the submit button.

The ACP will provide a discount of up to $30 per month towards broadband service for eligible households and up to $75 per month for households on Tribal lands.

National Verifier Application ID*

Kayenta Customer ID (optional)

Tribal ID (optional)

First Name*

Last Name*

Email*

Phone

+ () -

Address*

City*

State*

Zip*

I understand and agree to all of the following conditions:

For my household, I affirm and understand that the Affordable Connectivity Program is a federal government subsidy that reduces my broadband internet access service bill and if the program is discontinued, my household will be subject to the provider's undiscounted general rates, terms and conditions if my household continues to subscribe to the service.

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 income is 200% or less than the federal poverty guidelines.

I agree that if I move I will give my service provider my new address within 30 days.

I understand that I have to tell my service provider within 30 days if I do not qualify for the Affordable Connectivity Program anymore.

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 agree that all of the information I provide on this form may be collected, used, shared, and retained for the purpose 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 law 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.

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

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.

I was truthful about whether or not I am a resident of Tribal lands, as defined in this form.

Signature*

I understand this is a digital signature, and is the same as if I sign my name with a pen.