Your NACA ID

First Name

Last Name

Date of Birth

Street Address

Zip Code

Driver’s License#:

Phone Number

Email

Last 4 Digits SSN

People live in Household?

NAMES AND BIRTHDAYS OF ALL HOUSEHOLD MEMBERS

1) Full Name

Date of Birth

2) Full Name

Date of Birth

3) Full Name

Date of Birth

4) Full Name

Date of Birth

5) Full Name

Date of Birth

ARE YOU OR ANYONE IN YOUR HOUSEHOLD IN ANY OF THESE?

SSI Veterans Pension & Survivors Benefit Program SNAP Federal Public Housing Assistance Section 8 Reduced Price School Meal Program Federal Pell Grant in the current award year WIC Tribal Specific Program (Only choose if you live on tribal lands)

INCOME DOCUMENTS

The prior year's state, federal, or Tribal tax return (2020 1040, 2022 W2, or 2022 1099) Current income statement from an employer or paycheck stub (for 3 consecutive months) A Social Security statement of benefits (2022/2023 Award letter) An Unemployment or Workers Compensation statement of benefits A Federal, or Tribal notice letter of participation in General Assistance A Divorce Decree, Child Support Award Other official document containing income information

If the document doesn’t cover the full year provide documentation verifying income for at least three months in a row during 2023. Acceptable document file types re: jpg, jpeg, png, pdf, and gif.

Upload file types: jpg, jpeg, png, pdf, and gif

Household	48 States	Alaska	Hawaii
1	$29,160	$36,420	$33,540
2	$39,440	$49,280	$45,360
3	$49,720	$62,140	$57,180
4	$60,000	$75,000	$69,000
5	$70,280	$87,860	$80,820
6	$80,560	$100,720	$92,640
7	$90,840	$113,580	$104,460
8	$101,120	$126,440	$116,280
8+, add:	$10,280	$12,860	$12,820

AGREEMENT

By completing and submitting this application form I authorize the Neighborhood Assistance Corporation of America (“NACA”) including its affiliates and subsidiaries to submit the application to receive discounted cellular or broadband service through the Affordable Connectivity Program and/or the Lifeline Program using the information, documents, and authorizations I am providing on the NACA ACP & Tablet Application Initial I understand that the $20.00 cash requirement is being paid for by an ACP provider and therefore I am benefiting from the ACP program without having to make any payment. I acknowledge that to the best of my knowledge, No One at my household is receiving Affordable Connectivity Program-Supported Service from any other provider. By checking this box and your signature below, you are authorizing Excess Wireless, or its representatives to use an automated system to deliver telemarketing calls to the phone number you provide above using an automatic telephone dialing system, and/or an artificial or pre-recorded voice or text message. By continuing with your application, you affirm and understand that the Affordable Connectivity Program is an FCC benefit program that reduces your monthly Broadband invoice. The program will be in effect for an indefinite amount of time. At the conclusion of the program, you will be given 30 days’ notice and may elect to keep your plan at an un-discounted rate. As a participant you may transfer your ACP benefit to another provider. The Affordable Connectivity Program is limited to one monthly service discount and one device discount per household. You agree that you are activating your ACP benefit and service with Excess Wireless by submitting the application form and completing the eligibility verification and enrollment process.

TERMS & AGREEMENTS

I, my dependent, or other person in my household currently get benefits from the government program(s) listed on this form or my annual household income is 200% or less than the federal Poverty Guidelines (the amount listed in the Federal Poverty Guidelines table on this form). I agree that if I move, I will give my internet company my new address withing 30 days. I understand that I must tell my internet company within 30 days if I do not qualify for the ACP anymore, including:

1. I, or the person in my household that qualifies do not qualify through a government program orincome anymore.
2. Either I or someone in my household gets more than one ACP benefit.

I know that my household can only get one ACP benefit, and, to the best of my knowledge, my household does not get more than one ACP benefit. I understand that I can only receive one connected device (desktop, laptop, or tablet) through the ACP, even if I switch ACP companies. I agree that all the information I provide on this form may be collected, used shared, and retained for the purposes 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 laws 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. For my household, I affirm and understand that the ACP is a federal government subsidy that reduces my broadband internet access service bill and at the conclusion of the program, my household will be subject to the company’s undiscounted general rates, terms, and conditions if my household continues to subscribe to the service. 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. The ACP Administrator or my service provider may have to check whether I still qualify at any time. If I need to recertify my ACP benefit, I understand that I must respond by the deadline, or I will be removed from the Affordable Connectivity Program and my ACP benefit will stop. I was truthful about whether I am a resident or not of Tribal lands, as defined in the “your Information” section of this form. I understand this is a digital signature below and is the same as if I signed my name with a pen.