Authorization to Transfer Benefit

The signature provides acknowledgment to each of the following statements and authorizes BrightRidge to initiate ACP/ EBB benefit transfer from 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.