How to Qualify – Project Connect USA

⸺Project Connect⸺

Do I Qualify for ACP?

Please fill the following pre-qualification form and submit it in order to pre-qualify for the program

Check If I Qualify

Affordable Connectivity Program (ACP) | Form 5645 online

Please select the program you are currently enrolled in. Eligibility Programs (*)

Medicaid

Qualify through my Income

Supplemental Security Income (SSI)

Federal Public Housing Assistance (FPHA)

Federal Pell Grant for the current award year

Veterans Pension and Survivors Benefit Programs

Supplemental Nutrition Assistance Program (SNAP/Food Stamps)

Free & Reduced-Price School Lunch Program or School Breakfast Program

Affordable Connectivity Program (ACP) | Form 5645 online

First Name

Middle Name

Last Name

Date of Birth

Last 4 digits of your SSN(*)

What is the best way to reach you(*)

Mail

Phone

Text Message

Phone/Mobile

Address

Apt/Floor/Other

City

State

Zip Code

My Residential Address is(*)

Temporary

Permanent

Benefit Qualifying Person (BQP): Check if you are qualifying through a child or dependent in your household. Once checked please enter the child/dependent details.

Yes

First Name (Dependent)

Middle Name (Dependent)

Last Name (Dependent)

Date of Birth (Dependent)

Last 4 digits of your SSN(*)

Affordable Connectivity Program (ACP) | Form 5645 online

Please check all the following Disclosures:(*)

I hereby certify that I have read and understood the disclosures listed above regarding activation and usage requirements.

I authorize Project Connect and its contracted partners, for the purpose of applying for, determining eligibility, enrolling in and seeking reimbursement of Affordable Connectivity Program service and device benefits, to collect, use, share and retain my personal information, including but not limited to information required for the purpose of establishing eligibility for and enrolling in the ACP, and including, but not limited to, full name, full residential address, date of birth, last four digits of social security number, telephone number, eligibility criteria and status, the date on which the ACP service discount was initiated and if applicable, terminated, ACP connected device distribution date/ type/make and model/status, usage status and other compliance requirements, the amount of support being sought for the service and/or device, and information necessary to establish identity and verifiable address, to the Universal Service Administrative Company (USAC) to ensure proper administration of the ACP service and/ or connected device benefits. Failure to provide consent will result in me being denied the Emergency Broadband Benefit service and/ or the connected device benefits.

I agree that any state, local, Tribal government, school or school district, may share information about my receipt of benefits that would establish eligibility for the ACP, and that such information will be used only to determine ACP eligibility.

I give express consent for Project Connect and its contracted partners to contact me to validate my eligibility for or desire to participate in Project Connect's ACP offers, and other products and services via email, telephone, or text messaging. Text messaging and data rates may apply. Consent for calls and texts is optional and can be revoked at any time. For more information see our Terms and Conditions and Privacy Policy at www.projectconnectusa.com.

I understand that the Affordable Connectivity Program connected device discount is limited to one per household. If I received a connected device discount with Project Connect as part of the ACP program, I certify that I was charged $11.00 for the connected device. Additionally, I certify that to the best of my knowledge that no one in my household has received a connected device discount with the Affordable Connectivity Program.

I understand I have the right to enroll in the ACP service using non-electronic methods. I further understand that I have the right to withdraw this consent at any time prior to activation of my service. The Company has advised me that I may request a paper copy of my contract and associated fees by calling 1-866-350-0222.

I hereby authorize Project CONNECT to send me notifications, via text messages, emails, and phone calls (by automated telephone dialing system, manually, or with pre-recorded/ artificial voice messages) regarding my ACP benefit, marketing messages, and promotional offers. I may withdraw my consent to receive some of these messages by calling. Opting out will not affect the Company's ability to contact me with messages regarding the ACP program and/ or service functionality via the methods listed herein.

I acknowledge that I am providing the information I have included in this application to PROJECT CONNECT, LLC and further authorize PROJECT CONNECT, LLC to receive and use my information for enrollment verification and waste, fraud and abuse mitigation purposes. Additionally, I authorize PROJECT CONNECT, LLC to receive and use my historic ACP enrollment information for enrollment verification and waste, fraud and abuse mitigation purposes.

I agree that my service provider can give the ACP Program administrator all of the information I am giving on this form. I understand that this information is meant to help run the ACP Program and that if I do not let them give it to the Administrator; I will not be able to get ACP benefits.

ACP program participants are eligible to participate in the new federal government funded Affordable Connectivity Program (ACP). The Project Connect FREE ACP plan includes up to 10 GB of 5G/4G High Speed Data. To Opt-IN to this ACP plan, please read the following and OPT-IN below. The ACP is a program operated by the Federal Communications Commission (FCC) that provides discounts on monthly broadband Internet access service and certain connected devices. The ACP monthly service and device discounts are non-transferrable. An eligible household is limited to one monthly service discount and one device discount. ACP Program benefits may be obtained from any participating provider of your choosing and your monthly service benefit may be transferred to another provider at any time.

If/when the FCC announces the end of the ACP program or we end our promotional FREE ACP service offer, we will notify you and you will revert to receiving only the standard FREE ACP plan where available and if you are eligible. You may keep your ACP service by paying the applicable undiscounted rate of $40.00 plus fees and taxes. Our standard terms and conditions apply.

I understand that ACP benefits are limited to one per household. If I am found to already be receiving an ACP discount benefit from another provider, I understand my current benefit will be transferred to Project Connect. I consent to the transfer of my ACP discount benefit from my current ACP provider to Project Connect. For more information about ACP eligibility, specifics on Project Connect's ACP plan including upload/ download speeds, and general information on the program call us or visit www.projectconnectusa.com.

I hereby certify that I have read and understood the disclosures

Affordable Connectivity Program (ACP) | Form 5645 online

Device Copay Payment

The Affordable Connectivity Program (ACP) allows qualifying subscribers to claim a one time discount toward a tablet.

The FCC requires us to charge a copay amount.

Our Copay for an Android Tablet with 4G LTE Connectivity is a one-time $11.00

(A transaction of $11.00 will be drafted when the prospect subscriber is approved to receive a Tablet)

First Name On Credit Card

Last Name On Credit Card

Credit Card Number

CVV Code

Exp. Date

Address

Address On Credit Card

City On Credit Card

State On Credit Card

Zip Code On Credit Card