ACP Transfer DisclosureDisclosure of Affordable Connectivity Benefits Transfer. Consent(Required) I have read and agree to the terms and conditions listed below.I hereby consent and authorize the transfer of my Affordable Connectivity Program (ACP) benefits to PMT (transfer-in provider) from my previous Internet Service Provider (transfer-out provider): • I acknowledge that my ACP benefit discount will transfer to PMT (transfer-in provider). • I acknowledge that my ACP benefit will be applied to PMT (transfer-in provider’s) service and will no longer be applied to service retained from the transfer-out provider. • I acknowledge I may be subject to the transfer-out provider’s undiscounted rates as a result of the transfer if I elect to maintain service from the transfer-out provider. • I acknowledge that I am limited to one ACP benefit transfer transaction per service month, with limited exceptions for situations where I seek to reverse the unwanted transfer or am unable to receive service from a specific provider.Name(Required) Full Name Your PMT Account Number (Optional)Service Location Address(Required) Street Address City 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 State ZIP Code Mailing Address(Required) Street Address City 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 State ZIP Code Phone(Required)Date your ACP application was approved(Required) MM slash DD slash YYYY Email(Required) Last 4 of Social Security Number(Required)Date of Birth(Required) MM slash DD slash YYYY Qualifying Application ID #(Required)Please list the benefit-qualifying person's (BQP) info below.In some cases, an application may have been submitted under a name/person OTHER than the one listed above. Name First Last Date of Birth MM slash DD slash YYYY Last 4 of Social Security #Consent(Required) I understand and agreePlease check the box above to confirm your understanding that: 1. You are enrolled in a government program that reduces your broadband Internet bill by $30 per month. 2. You may obtain broadband service supported by the ACP Program from any participating provider of your choosing. 3. You may transfer your ACP Program benefit to another provider at any time. 4. By submitting this form you agree to allow PMT to submit this information to USAC to verify and confirm your eligibility.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.