Affordable Connectivity Program Application

Affordable Connectivity Program (ACP) Application

To apply for the Affordable Connectivity Program, please follow the steps listed below. Please note, the information must match the information submitted and approved by the National Verifier to prevent delays in your Affordable Connectivity Program credits being applied to your broadband account.

Once the request has been received BrightRidge will:

Verify your eligibility for the benefit program
Notify you if additional information is needed
Apply the Affordable Connectivity discount to your account within one billing cycle

Please note, submission of the BrightRidge ACP Application does not guarantee $30 ACP credit on your Broadband account. You will receive email communication from BrightRidge Broadband at acpapplications@brightridge.com after submitting the application, including confirmation the application has been received, potential next steps, and notice of approval.

If you have any questions or concerns with the Affordable Connectivity Program, we will be here to help guide you through this process. You do have a right to file a complaint with the FCC by visiting the FCC Consumer Complaint Center website or by contacting the FCC Consumer Complaint Center by calling 1-888-225-5322.

Applicant
ACP Application ID Received from National Verifier* *
First Name *
Middle Name
Last Name *
Suffix
Date of Birth *
Last 4 of Social *
Service Address Information *
Street Address (Please include any apartment / unit #'s in this field) City ZIP Code
Phone *
Email *
Benefit Qualifying Information
Do you qualify for the Affordable Connectivity Program through your child or a dependent? *
- Yes, I qualify through my child or dependent
- No, I qualify independently
We need the following information of the Benefit Qualifying Individual:
Qualifying Dependent Name *
First Last
Last 4 of Social *
Date of Birth *
Transferring Benefit
Are you transferring your ACP/ or EBB Benefit to BrightRidge from another provider?
Authorization to Transfer Benefit

The acknowledgment and signature to each of the follow statements below authorizes BrightRidge to initiate ACP/EBB benefit transfer from your current provider:
- That the household will be transferring its ACP/EBB benefit to BrightRidge
- That the effect of the transfer is that the ACP benefit will be applied to BrightRidge service and will no longer be applied to service retained from the transfer-out provider;
- That the household may be subject to the transfer-out provider’s undiscounted rates as a result of the transfer if the household elects to maintain service from the transfer-out provider, and that
- The household is limited to one ACP-transfer transaction per service month with limited exceptions to reverse an improper transfer or address situations impacting the household’s receipt of ACP-supported service from a particular provider.
Signature *
Date *
MM slash DD slash YYYY
Agreement
The Affordable Connectivity Program, (ACP) previously the Emergency Broadband Benefit Program, is a government program that reduces an eligible household’s internet service bill. Discounts are temporary credits limited to one per household and vary based on customer location and qualifying service. BrightRidge is not responsible for program qualification decisions and cannot make any guarantees of eligibility, qualification for certain credit amount or length of time the credit will be available to be applied to your monthly broadband bill. If the program ends, the customer will be subject to the BrightRidge’s undiscounted rates and general terms and conditions. The Affordable Connectivity Program benefit may be used with a provider of your choosing, such as for BrightRidge, at the same terms available to households that are not eligible for the ACP-supported services. The ACP credit may also be moved to another provider at any time. Please note, transferring benefit to another provider, could potentially impact your monthly service credit with BrightRidge. In addition, customers who demonstrate 90 consecutive days of non-payment will be subject for disconnect. Please note, the information you are providing may be considered sensitive information. While privacy laws give you the right to limit how we use or disclose such data, we are required by other laws to keep and store the information for certain periods of time. By using this service, you agree that we may use , disclose, or store the data as required by law and necessary for us to provide the services sought, in accordance with our privacy notice and policy found at https://www.brightridge.com/resources/-new-resources. As your trusted provider, we value our customers. If you wish to file a complaint regarding the Affordable Connectivity Program, please contact the Commission’s Consumer Complaint Center. Details and contact information can be found at www.mybrightridge.com.
Your electronic signature indicates you have reviewed and agree to the terms and conditions listed above and provide consent for BrightRidge to enroll you the consumer in the Affordable Connectivity Program.
- Agree
Signature (Type full name) *
Todays Date *
MM slash DD slash YYYY

Affordable Connectivity Program Application

Affordable Connectivity Program (ACP) Application

Authorization to Transfer Benefit

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