Consent Form


Date of Birth :

 * Only Last 4 digits of SSN *

* Note: P.o. Box and Business Addresses are not Acceptable Please Provide a Service Address *

  1. I am older than 18 years old.
  2. I am the authorized person to make decisions for Internet services and to change the Internet Service Provider.
  3. I have good Cellular Network at my residence.
  4. I am selecting City Communication as my Wireless Broadband Service provider
  5. I understand that my $30.00 will be paid by the Government to my Broadband Service Provider.
  6. I am aware that this may take 5 to15 days to get the Internet services depend on the early possible window.
  7. I am aware that if I am already getting the device under ACP, I will not be getting the device anymore.

I'm going to go over the required information to participate in the Affordable Connectivity Program. Answering affirmatively is required in order to get enrolled in the Affordable Connectivity Program in my state. This authorization is only for the purpose of verifying my participation in this program and will not be used for any purpose other than Affordable Connectivity Program (ACP). I am authorizing the Company, City Communication to access any records required to verify my statements on this form and to confirm my eligibility for the Affordable Connectivity Program.

For my household, I affirm and understand that the ACP is a temporary federal government subsidy that reduces my broadband internet access service bill and at the conclusion of the program, my household will be subject to the provider's undiscounted general rates, terms, and conditions if my household continues to subscribe to the service.

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).

I agree that if I move I will provide my new address to my service provider within 30 days.

I understand that I have to tell my service provider within 30 days if I do not qualify for ACP benefit anymore, including: I, or the person in my household that qualifies, do not qualify through a government program or income anymore.

No one else is getting Affordable Connectivity Program benefit at my house right now.
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 providers..

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.

I agree that City Communications can contact me at any time to follow up on my subscription and future service offerings. I understand and agree to the terms and conditions of the ACP program. If I am enrolled or Transferred with another provider for any reason, in the mid-month or at any time of the preceding month I authorize City Communications to transfer my services back to City Communications as my ACP service provider. All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.

All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.

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.

I hereby certify that I have read this thoroughly and agreed to this disclosure.


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Signature Certificate
Document name: Consent Form
lock iconUnique Document ID: 242076185e03d19c2adf9bc1f069899689c6fb27
Timestamp Audit
April 15, 2022 12:41 pm -03Consent Form Uploaded by Alex Johns - IP