AffordableConnectivity.gov
Affordable Connectivity Program Annual Recertification Form (FCC Form 5648) Instructions
Page 1: About the Affordable Connectivity Program
The Affordable Connectivity Program (ACP) is a federal government program that provides a $30 non-
Tribal or $75 Tribal monthly discount on internet services and, where available from participating
internet companies, a one-time discount on a connected device for qualifying low-income consumers.
The ACP provides one monthly internet discount and a one-time connected device benefit per
household.
Rules
If you qualify, your household can receive a monthly ACP benefit of up to $30 to cover the cost of your
internet service and up to $75 if you reside on qualifying Tribal lands. Through the program, your
internet company may also offer a one-time internet connected device benefit of up to $100 for a
desktop computer, tablet, or laptop with a required co-payment of more than $10 but less than $50.
Your household cannot get the ACP benefit from more than one company. You are only allowed to
receive one ACP benefit per household, not per person.
The Affordable Connectivity Program is separate from the FCC's Lifeline Program. If your household
qualifies for both programs, you can apply for and receive both benefits on the same or different
service. For example, you could apply the Lifeline benefit to a mobile service and apply an ACP benefit
to an internet service to your home. You could also apply your Lifeline and ACP benefit to a single
internet service from the same company.
If you no longer qualify for the ACP benefit (for example, your income exceeds the income level or you
no longer participate in a qualifying benefits program), you must notify your ACP internet company or
the ACP administrator within 30 days.
Note: Internet companies must also meet certain criteria to participate in the ACP. Check with your
internet company to determine if it participates. If you are looking for an internet company, please visit
Companies Near Me
to find a participating internet company in your area.
What is a household?
A household is a group of people who live together and share income and expenses (even if they are not
related to each other). If more than one person in your household participates in the ACP, you are
breaking the FCC's rules and will lose your benefit. If you previously completed a one per household
worksheet you do not need to complete a new one for purposes of recertification, unless you have
experienced changed circumstances relevant to whether you are only receiving one benefit per
household.
Do not give your benefit to another person
The ACP benefit is non-transferable. You cannot give your benefit to another person, even if they qualify
for the ACP.
Be honest on this form
You must give accurate and true information on the form and on all ACP related forms or
questionnaires. If you give false or fraudulent information, you will lose your benefit (i.e., de-enrollment
or being barred from the program) and the United States government can take legal action against you.
This may include (but is not limited to) fines or imprisonment.
You may need to show other documents
If the ACP Administrator is not able to validate that you or someone in your household qualify by
checking available electronic resources (including eligibility databases for the FCC's government agency
partners), you may need to provide additional documents. For example, you may need to provide an
official document that proves your participation in a qualifying government assistance program, your
income, or your identity. Please include copies of your proof documentation when you submit your
applications to speed up processing time.
How to Recertify
To recertify your eligibility for the Affordable Connectivity Program benefit, fill out the required sections
of this form, initial every agreement statement, and sign on page 6. You can also recertify online at
AffordableConnectivity.gov
for fastest processing.
Mail the form to this address:
USAC
ACP Support Center
P.O. Box 9100
Wilkes-Barre, PA 18773
Page 2: Your Information
All fields are required unless otherwise indicated. Use only CAPITALIZED LETTERS and black ink to fill out
this form.
1. What is your full legal name? Enter your first name on the first line, middle name (optional) on
the second line in the first set of boxes, and last name on the third line. Include any suffix
(optional) on the second line in the second set of boxes. Please use your full, legal name that
you use on official documents. Do not use a nickname.
2. What is your phone number? Enter your phone number, if you have one.
3. What is your date of birth? Enter your birth month, date, and year in that order.
4. What is your email address? If you have an email address, enter it here. Providing an email
address is recommended so USAC can send you status updates about your recertification .
5. Identity Confirmation. Please select one of the following to confirm your identity.
a. What are the last four digits of your Social Security Number (SSN4)? If you provided
your Social Security Number on your application, please check the box to the left of this
subsection and enter the last four digits of your Social Security Number (SSN4) in the
space provided immediately below. If you did not provide your Social Security Number
or Tribal ID upon enrollment, enter in 0000 in the space provided immediately below.
OR
b. Tribal Identification Number. If you provided your Tribal Identification Number upon
enrollment, please check the box to the left of this subsection and enter the number in
the space provided immediately below.
Page 3: Your Information (Continued)
6. What is your home address? Enter your home address. This should be the address where you’ll
receive service and cannot be a P.O. Box. It should include your street number and name on the
first line, your apartment or unit number (if you have one) on the second line in the first set of
boxes, the city on the second line in the second set of boxes, the state abbreviation on the third
line in the first set of boxes, and the zip code on the third line in the second set of boxes. If you
move, you must update your address with your internet company within 30 days.
7. Is this a temporary address? Check yes or no.
8. If you live on qualifying Tribal lands, check the box in question 8. Under ACP rules, Tribal lands
include any federally recognized Indian tribe’s reservation, Pueblo, or colony, including former
reservations in Oklahoma; Alaska Native regions established pursuant to the Alaska Native
Claims Settlement Act (85 Stat. 688); Indian allotments; Hawaiian Home Lands—areas held in
trust for Native Hawaiians by the state of Hawaii, pursuant to the Hawaiian Homes Commission
Act, 1920 (July 9, 1921, 42 Stat. 108, and the following, as amended); and any land designated as
such by the FCC pursuant to the designation process in the FCC’s Lifeline rules. A map of
qualifying Tribal lands is available on USAC's website:
https://www.affordableconnectivity.gov/wp-content/uploads/acp/documents/fcc_tribal_lands_map.pdf
9. What is your mailing address? Enter your mailing address only if it is different from your home
address. It should include your street number and name on the first line, your apartment or unit
number (if you have one) on the second line in the first set of boxes, the city on the second line
in the second set of boxes, the state abbreviation on the third line in the first set of boxes, and
the Zip code on the third line in the second set of boxes.
Page 4. Qualify for the ACP
Fill out this section to show that you, your dependent, or someone in your household continues to
qualify for the ACP. You can qualify through certain government assistance programs or through your
income (you do not need to qualify through both). If you are asked to recertify, you will receive a
written notice from USAC’s ACP Support Center and must recertify within 60 days, or you will lose
your ACP benefit. If you are required to provide proof of your eligibility, the letter will provide
information on documentation you need to submit.
10. Qualify Through a Government Assistance Program. Check the box next to all the programs
that you or someone in your household participate in:
a. Supplemental Nutrition Assistance Program (SNAP, also called Food Stamps)
b. Supplemental Security Income (SSI)
c. Medicaid
d. Federal Public Housing Assistance (FPHA) (including Housing Choice Voucher (HCV)
Program (Section 8 Vouchers), Project-Based Rental Assistance (PBRA)/202/811, Public
Housing, and Affordable Housing Programs for American Indians, Alaska Natives or
Native Hawaiians).
e. Veterans Pension or Survivors Benefit Programs
f. Federal Pell Grant for the current award year
g. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
h. Free and Reduced-Price School Lunch Program or School Breakfast Program, or
enrollment in a Community Eligibility Provision School. If you choose this option, please
enter your school name, school district, and state.
Tribal Specific Programs
i. Bureau of Indian Affairs (BIA) General Assistance
j. Tribal Temporary Assistance for Needy Families (Tribal TANF)
k. Food Distribution Program on Indian Reservations (FDPIR)
l. Tribal Head Start (only households that meet the income qualifying standard)
OR
Page 5. Qualify for the ACP (Continued)
Qualify Through Household Income: If you qualify for the ACP through your income, complete
questions 11 and 12. You qualify through income if your income is at or below 200% of the Federal
Poverty Guidelines. The Federal Poverty Guidelines are typically updated at the end of January each
year.
11. Including you, how many people live in your household? Check the box next to the appropriate
number.
12. Is your income the same or less than the amount listed on the recertification form for your
state and household size? To find your state’s income threshold, follow the line across from
your household number to find the ACP’s income limits. Check “yes” or “no” to indicate if your
income is at or below the number listed. The first column is for households in the lower 48
states, DC, and territories. The second column is the income limit for Alaska and the third
column is for Hawaii.
Page 6: Agreements and Signature
Initial next to each box to agree to the statement and sign and date the form. If you do not initial each
statement, your recertification form will be considered incomplete and you will lose your ACP benefit
if you fail to submit a complete form by the deadline.
I agree, under penalty of perjury, to the following statements:
13. I (or 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).
14. I agree that if I move I will give my internet company my new address within 30 days.
15. I understand that I have to tell my internet company within 30 days if I do not qualify for ACP
anymore, including:
1) I, or the person in my household that qualifies, do not qualify through a government program
or income anymore.
2) Either I or someone in my household gets more than one ACP benefit.
16. I know that my household can only get one ACP benefit and, to the best of my knowledge, my
household is not getting 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.
17. I agree that all of 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.
18. For my household, I affirm and understand that the ACP is a federal government subsidy that
reduces my broadband internet access service bill and that 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.
19. All the answers and agreements that I provided on this form are true and correct to the best of
my knowledge.
20. 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 certification below applies to all consumers and is required to process your recertification
form.
21. I was truthful about whether or not I am a resident of Tribal lands, as defined in the Your
Information section of this form.
22. Signature: Please sign the form.
23. Today’s Date: Enter today’s date.
Page 7. Representative Information and Privacy Act Statement
Answer only if a representative submits this form. Representatives who help consumers apply (such as
internet company agents, state and Tribal partners, etc.) are required to register in the Representative
Accountability Database and must entire in their Representative ID in this section.
24. What is your Representative ID? A representative who submits this form must enter their
representative ID as registered in the Representative Accountability Database.
By providing a phone number, you consent to letting USAC contact you at that phone number via
artificial or prerecorded voice message or text for important reminders and updates about your ACP
benefit. For text messages, message and data rates apply. Text STOP to end messages.
For any questions, please contact Universal Service Administrative Company
Website: AffordableConnectivity.gov
Phone: Call the ACP Support Center at 1-877-384-2575
Email: [email protected]
How Does the ACP Protect Consumers?
The rules protect Affordable Connectivity Program recipients by:
• Empowering consumers to choose the service plan that best meets their needs (including a
plan they may already be on);
• Ensuring consumers have access to supported internet services regardless of their credit
status;
• Prohibiting companies from excluding consumers with past due balances or prior debt from
enrolling in the program;
• Preventing consumers from being forced into more expensive or lower quality plans in order
to receive the ACP;
• Reducing the potential for bill shock or other financial harms;
• Allowing ACP recipients to switch companies or internet service offerings; and
• Providing a dedicated FCC process for ACP complaints at
https://consumercomplaints.fcc.gov.
Privacy Act Statement
This Privacy Act Statement explains how we are going to use the personal information you are entering into
this form.
The Privacy Act is a law that requires the Federal Communications Commission (FCC) and the Universal Service
Administrative Company (USAC) to explain why we are asking individuals for personal information and what
we are going to do with this information after we collect it.
Authority: 47 U.S.C. §254; 47 U.S.C. §1752; 47 CFR Part 54, Subparts E and R.
Purpose: We are collecting this personal information so we can verify your identity and that you qualify for
the Lifeline program or similar programs that use income or consumer participation in certain government
benefit programs as eligibility criteria, such as the Affordable Connectivity Program. We access, maintain, and
use your personal information in the manner described in the Lifeline System of Records Notice (SORN),
FCC/WCB-1, and the Affordable Connectivity Program SORN, formerly known as the Emergency Broadband
Benefit Program SORN, FCC/WCB-3, both available at
https://www.fcc.gov/managing-director/privacy-
transparency/privacy-act-information#systems/.
Routine Uses: We may share the personal information you enter into this form with other parties for specific
purposes, such as:
• With contractors that help us operate the Lifeline program and similar programs that use income or
consumer participation in certain government benefit programs as eligibility criteria, such as the
Affordable Connectivity Program;
• With other federal and state government agencies and Tribal agencies that help us determine your
Lifeline eligibility and eligibility for similar programs that use income or consumer participation in certain
government benefit programs as eligibility criteria, such as the Affordable Connectivity Program;
• With the telecommunications companies and broadband providers that provide you Lifeline service and
service under a similar program that uses income or consumer participation in certain federal benefit
programs as eligibility criteria, such as the Affordable Connectivity Program;
• With other federal agencies or to other administrative or adjudicative bodies before which the FCC is
authorized to appear;
• With appropriate agencies, entities, and persons when the FCC suspects or has confirmed that there has
been a breach of information; and
• With law enforcement and other officials investigating potential violations of Lifeline and other program
rules.
A complete listing of the ways we may use your information is published in the Lifeline SORN and the
Affordable Connectivity Program SORN (formerly known as the Emergency Broadband Benefit Program SORN)
described in the "Purpose" paragraph of this statement.
Disclosure: You are not required to provide the information we are requesting, but if you do not, you will not
be eligible to receive Lifeline services under the Lifeline Program rules, 47 C.F.R. Part 54, Subpart E, or benefits
under the Affordable Connectivity Program rules, 47 C.F.R. Part 54, Subpart R.
