Lifeline InformationToday's Date(Required) MM slash DD slash YYYY Approved Application ID(Required) Legal Name(Required) First Last Date of Birth (mm/dd/yyyy)(Required) Month Day Year Social Security Number (last 4 only)(Required)Phone(Required)SCI Fiber Account Number(Required) Address(Required)(address must be your physical, primary address) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Are you transferring your Lifeline benefit from another telecommunications provider?(Required) Yes No Is the benefit qualifying person the person listed above?(Required) Yes No Qualifying Participant Name First Last Date of Birth (mm/dd/yyyy) Month Day Year For verification purposes, please provide the last 4 digits of the Qualifying Participant's Social Security Number Consent By checking the box to the left, I certify that the above-named “qualifying participant” is a current member of my household qualifying for the Lifeline Program.Consent(Required)The Affordable Connectivity Program (ACP) and Lifeline are government programs developed by the Federal Communications Commission (FCC) to reduce your broadband and other internet access service fees. You are not required to sign up for ACP-supported service to obtain or continue to obtain Lifeline-supported services. Your household must meet eligibility criteria to participate in ACP and Lifeline. Only certain SCI Fiber service areas and service plans are eligible to receive a discount under Lifeline. We may request additional information regarding your eligibility status at any time and you may be de-enrolled from the programs and no longer receive the discount if you no longer meet the eligibility criteria. SCI REMC may disconnect your ACP-supported service after 90 consecutive days of non-payment. ACP and Lifeline are programs of the federal government and may be ended at any time. If the program is discontinued and you choose to continue to receive service from SCI REMC, you will be subject to our full rates and charges. SCI REMC will inform you if the programs are scheduled to end, and when your new rates will take effect. The information you are providing may be considered sensitive personal information. While privacy laws give you the right to limit how we use or disclose such data, we are required by other laws to keep and store the information for certain periods of time. By using this service, you agree that we may use, disclose, or store the data as required by law and necessary for us to provide the services sought, in accordance with our Privacy Policy. To enroll you in the Affordable Connectivity Program, we must transmit the following information about your enrollment to the administrator of the Program, the Universal Service Administrative Company (USAC) to ensure the proper administration of the program: your full name, full address, date of birth, last four digits of your Social Security Number (if applicable), and telephone number associated with your enrollment along with the same information (e.g. name, address date of birth, last four of their Social Security Number) of your minor child or dependent if your child or dependent is the basis for qualifying for benefits under the program. If you consent to us transmitting this information, please indicate so by checking below. If you do not consent, we will not be able to enroll you in the program and you will not receive the benefit. For more information about the Affordable Connectivity Program visit the Affordable Connectivity Program website. Information on Lifeline can be found on the Lifeline Support website. The subscriber is limited to one ACP benefit transfer transaction per service month, with limited exceptions for situations where the subscriber seeks to reverse an unwanted transfer or is unable to receive service from a specific provider. If transferring your ACP benefit from another service provider to SCI REMC your ACP benefit will be applied to your SCI Fiber service and will no longer be applied to service retained from the transfer-out provider and you may be subject to the transfer-out provider’s undiscounted rates for any service you elect to maintain from the transfer-out provider. I was provided enrollment and transfer disclosures, read and agree to the above, and consent to having my Affordable Connectivity program discount applied to my SCI Fiber broadband Internet service. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Applicant Electronic Signature (Full Name)(Required) Email(Required) EmailThis field is for validation purposes and should be left unchanged.
