Full Name

Phone *

Your date of birth (MM/DD/YYYY) *

Email *

Last Four Digits of Social Security Number *

ACP Application ID

Address (please include city, state, & zip) *

Mailing Address (if different)

MetaLINK Technologies account number if you currently have our service

If you qualified through a dependent in your household, provide:

Their Name

Their Date of Birth (MM/DD/YYYY)

Their Last Four Digits of Social Security Number

Application ID Number

I understand the following, (By checking each box you agree to the following statements)

Affordable Connectivity Program (ACP) is a federal government benefit program operated by the Federal Communications Commission that provides a discount up to $30 on my monthly Internet service bill. *

I Agree

Households are eligible to participate in ACP by meeting one of the following criteria: (1) household income is at or below 200% of the Federal Poverty Guidelines, (2) participating in assistance programs such as Lifeline, SNAP, Medicaid, Federal Public Housing Assistance, SSI, WIC, the National School Lunch or Breakfast Program, including through the USDA Community Eligibility Provision, or (3) receipt of a Federal Pell Grant during the current award year. *

I Agree

Only one monthly Internet service discount is allowed per household. A household is defined as anyone living at the same address who share income and household expenses. This program is non-transferable to any other individual or household. *

I Agree

I may choose to participate in the ACP from any participating service provider and I may transfer the ACP benefit to another provider at any time during this program. *

I Agree

I authorize MetaLINK Technologies to disclose and transmit my information to the Universal Service Administrative Company and the National Lifeline Accountability Database to verify and enroll my household in the ACP program. Information this applies to may include but not be limited to my name, my dependent’s name, date of birth, last four digits of social security number or Tribal identification number, address, telephone number, type of service, start date of service, and termination date. *

I Agree

I understand if I cannot demonstrate eligibility, I will not be enrolled or may be de-enrolled if a I am no longer eligible. *

I Agree

I may apply the ACP benefit of any Internet service offering of MetaLINK Technologies at the same general terms and conditions available to households that are not eligible for the same ACP supported service. *

I Agree

I understand the ACP will not be prorated for a partial month of service or enrollment and may be less than the full benefit during the final month of the program when program funding is depleted. *

I Agree

I understand my ACP eligible Internet service may be disconnected after 90 consecutive days of non-payment. *

I Agree

I will be subject to the MetaLINK Technologies undiscounted rates and general terms and conditions if Affordable Connectivity Program ends, or if I transfer my ACP benefit but continue to receive service from MetaLINK Technologies or upon de-enrollment from the ACP. *

I Agree

I may file a complaint against MetaLINK Technologies via the FCC’s Consumer Complaint Center. *

I Agree

I will notify MetaLINK Technologies if I no longer choose to continue MetaLINK Technologies Internet service. *

I Agree

By checking all boxes above and signing this form, I confirm that I have reviewed the above disclosures about the ACP, consent to apply my ACP program benefit to my Internet service from MetaLINK Technologies and that all the above is true and complete to the best of my knowledge.

Signature *

Clear

Date

Any questions, call 888-999-8002 or email [email protected].

This form must be signed and returned before MetaLINK Technologies can apply the ACP program benefit to your Internet service.