Service Electric Cable TV and Communications

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Call 610-865-9100

610-865-9100

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:
E1 – Medicaid
E2 – Supplemental Nutrition Assistance Program (SNAP)
E3 – Supplemental Security
E4 – Federal Public Housing Assistance
E8 – Bureau of Indian Affairs General Assistance
E9 – Tribal Temporary Assistance for Needy Families (Tribal TANF)
E10 – Food Distribution Program on Indian Reservations (FDPIR)
E11 – Head Start
E13 – Eligibility Based on Income
E15 – Veterans Pension or Survivors Pension
E50 – School Lunch/Breakfast Program
E51 – Federal Pell Grant
E53 – Existing low-income program
E54 – Added and accepted (WIC)
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 Agree

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

Transfer Disclosure Statements

I acknowledge I am transferring my Affordable Connectivity Program discount to Service Electric Cable T.V.
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.
I am giving my consent to Service Electric Cable T.V. to transfer my ACP benefit.

I Agree

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.
Yes
No
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