ACP Form

The National Verifier, not HES/energynet, determines your eligibility to receive ACP. If you do not currently receive the Lifeline discount and
have not qualified for ACP through the National Verifier, please visit www.affordableconnectivity.gov to apply. Only persons who
have been determined to be eligible for ACP by the National Verifier should complete this Enrollment Form. If you have qualified for both Lifeline and ACP, click here.

This signed Affordable Connectivity Program (ACP) Enrollment Form is required to enroll you in HES/energynet’s ACP
Program. The information you enter on this Enrollment Form must be exactly the same as what you provided the National Verifier to receive eligibility approval, which expires after 45 days. Submitting this form does not guarantee an immediate ACP discount with HES/energynet.

*Indicates a field that must be completed.

ACP Enrollment Form

Verfication*
- By checking this box, I verify that I have read the above paragraphs.
National Verifier Application ID*
Name*
First Middle Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Last 4 digits of SSN*
HES/energynet Phone Number (If a current customer)
HES/energynet Account Number (If a current customer)
Email Address*
Enter Email Confirm Email
RESIDENTIAL ADDRESS
Must be a street address (not a P.O. Box) and your principle residence
Street Address (911 Address)*
Street Address Address Line 2 City State ZIP Code
Mailing Address*
Street Address Address Line 2 City State ZIP Code
QUALIFICATIONS THROUGH DEPENDENT
Complete if you qualified in the National Verifier through a child or dependent in your household.
Name of Dependent
First Middle Last
Dependent's Date of Birth
Date Format: MM slash DD slash YYYY
Dependent's Last 4 Digits of Social Security Number
I understand I can only get one ACP discount per month, and if I change my ACP benefit to HES/energynet, I will no longer receive the benefit with any other company.*
- I agree
BENEFIT TRANSFER REQUEST (If applicable) By transferring my ACP-support to HES/energynet, I understand that the ACP benefit will be applied to my HES/energynet ACP-supported broadband and will no longer be applied to any services that I may keep with my prior provider. My household may be subject to my prior provider’s undiscounted rates as a result of the transfer for any services that I may maintain with that prior provider. My household is limited to one ACP-transfer per month with limited exceptions to reverse an improper transfer or address situations impacting my household’s receipt of ACP-supported service from a particular provider. I currently receive ACP benefits from another carrier, and I request that HES/energynet submit a Benefit Transfer on my behalf on the date below.
- I agree
CERTIFICATIONS
I authorize government agencies and their authorized representatives to discuss with, receive from and provide information to HES/energynet that is relevant to my eligibility to receive ACP benefits from HES/energynet. I consent and give permission for HES/energynet to transmit any of my personal information disclosed on this Enrollment Form to verify my eligibility with the Universal Service Administrative Company.*
- I agree
I affirm that I understand the ACP Program is a temporary federal government subsidy that temporarily reduces my broadband internet access service bill and at the conclusion of the ACP Program, I will be subject to HES/energynets' undiscounted general, rates, terms, and conditions if I continue to subscribe to the service.*
- I agree
I hereby elect to continue to subscribe to the service upon the conclusion of the ACP Program and understand that I will remain subscribed to the service until such time as I affirmatively contact HES/energynet and either (i) cancel my service or (ii) switch to an alternative, lower-priced broadband plan. I make this election with the understanding that in the final month of the ACP Program, the ACP discount may be reduced. If this box is not checked, HES/energynet will stop providing internet service to the household on the applicable service line at the conclusion of the ACP Program. Notwithstanding this election, I understand that I may contact HES/energynet and cancel my service at any time.*
- I agree
I understand that a new certification will be added to the ACP Application that a consumer must complete prior to submitting the application. This certification specifies that USAC or a consumer’s service provider may verify that the consumer still qualifies for the ACP benefit at any time.*
- I agree
AFFORDABLE CONNECTIVITY PROGRAM (ACP) NOTICES AND DISCLOSURES
By signing this form, I give my affirmative consent that I want to participate in the Affordable Connectivity Program with HES/energynet and that I understand the following terms apply: * Affordable Connectivity Program (“ACP”) is a government program that reduces my broadband internet access service bill by up to $30 per month. * My household may obtain ACP-supported broadband service from any participating provider of its choosing and I may transfer my ACP benefit to another provider at any time. * My household may apply the ACP benefit to any broadband service offering of HES/energynet at the same terms available to households that are not eligible for ACP-supported service. Unless otherwise stated herein, HES/energynet broadband services are subject to the HES/energynet Terms of Service found here. * My broadband service will be subject to HES/energynet's undiscounted rates and general terms and conditions if the program ends, if I transfer my benefit to another provider but continue to receive service from HES/energynet, or upon de-enrollment from the Affordable Connectivity Program. * My broadband shall not be subject to early termination fees if I choose to terminate or modify my broadband service during my participation in the ACP or upon receiving notice of the benefit ending. * My household is limited to one ACP benefit and should any other member of my household receive an ACP benefit, my household may be subject to de-enrollment from the Affordable Connectivity Program. * HES/energynet may disconnect my ACP-supported broadband service after 90 consecutive days of non-payment. Services other than ACP-supported broadband may be disconnected for non-payment according to HES/energynet’s normal processes. * Information I provide to HES/energynet may be collected, used, shared, and retained for the purposes of compliance with the ACP Program. * Ongoing eligibility in the ACP program is subject to annual reverification. * My household may file a complaint against its provider via the Commission’s Consumer Complaint Center at (877) 384-2575.
- I agree
APPLICANT SIGNATURE
By my electronic signature below, I certify that the information provided above is true and correct, and agree to the above Certifications. I further certify that I have read and understand the above Notices and Disclosures of this Enrollment Form.
Name*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY
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*You may file complaint against your provider via the FCC Consumer Complaint Center. For more information, click here.

ACP Enrollment Form

RESIDENTIAL ADDRESS

QUALIFICATIONS THROUGH DEPENDENT

CERTIFICATIONS

AFFORDABLE CONNECTIVITY PROGRAM (ACP) NOTICES AND DISCLOSURES

APPLICANT SIGNATURE