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Please fill out the following ACP (formerly EBB) Form.
PLEASE NOTE: you must be sure that you qualify for the program before receiving your benefit. Please visit ACPBenefit.org to check if you qualify and apply for the ACP.



First Name:


Middle Name/Initial:


Last Name:


Street Address:


City, State Zip:


Phone Number:


Email Address:


Last 4 Digits of SSN:


Date of Birth:
  

SECTV Account Number (for exisiting customers):


NLAD Customer Eligibility Number (Lifeline):


Eligibility Code:














Benefit Qualifying Person's School Name (only required for Eligibility Code E50):


Benefit Qualifying Person's First Name (only required if different than applicant):


Benefit Qualifying Person's Middle Name/Initial (only required if different than applicant):


Benefit Qualifying Person's Last Name (only required if different than applicant):


Benefit Qualifying Person's Date of Birth (only required if different than applicant):
  

Benefit Qualifying Person's Last 4 Digits of SSN (only required if different than applicant):


I am aware that ACP is a temporary program and that I am responsible for all charges above the $30.00 credit allowed. I agree to the terms of this service.


I am aware that the program may end mid month and I will receive a partial credit the last month.


Transfer Disclosure Statements
  1. I acknowledge I am transferring my Affordable Connectivity Program discount to Service Electric Cable T.V.
  2. I am aware I will no longer receive my Affordable Connectivity Program benefit from my previous provider, and I am aware that I will be billed un-discounted rates from my previous provider if I elect to keep their services or if I do not contact them to cancel services.
  3. I am giving my consent to Service Electric Cable T.V. to transfer my ACP benefit.


I am opting to continue Internet service after the program ends. If yes, I agree that I will be responsible for service billing at the standard monthly rates.


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