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Universal Service Administrative Company | www.ACPbenefit.org
Need help? Call the Affordable Connectivity Support Center at 1-877-384-2575
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; Consolidated Appropriations Act, 2021, Public Law 116–260, div. N, tit. IX, § 904, as modified by the
Infrastructure Investment and Jobs Act, Public Law 117-58, div. F, tit. V, secs. 60501, 60502(a)-(b); 47 CFR Part 54, Subparts E and P.
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 o
r 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 P.
Initial
A
6. I live at an address with more than one household.
Initial
B
7. I understand that the one-per-household limit is a Federal Communications Commission
(FCC) rule and I will lose my Affordable Connectivity Program benefit if I break this rule.
8. Signature
9. Today’s Date
Agreement
Please initial the
agreement below and
sign and date this
worksheet. Submit this
worksheet with your
Affordable Connectivity
Program Application
Form.
I consent to let USAC contact me at the phone
number I provided for important reminders and
updates to my ACP service. Message and data
rates may apply. Text STOP to end messages.
FCC FORM 5646
Affordable Connectivity Program
Household Worksheet
