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Werks Mobile

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1. What is your full legal name? 


The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

 2. Your Phone Number?

3Your Date Of Birth?

4Your Email

(a) What are the last four digits of your Social Security Number (SSN)? If you did not provide your SSN or Tribal ID upon enrollment, please enter 0000.



(b) What is your Tribal ID? I do not have a Social Security Number and was enrolled with my Tribal ID. 

6What is your home address? (The address where you will get service. Do not use a P.O. Box.)


7Do you live on Tribal lands ?


8Check all programs that you or someone in your household have:



Tribal Specific Programs

9. Upload document of your government assistance.

10. Interested In ?

11I (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.

12I agree that if I move I will give my internet company my new address within 30 days.

13. I give Werks Mobile, Inc. permission to enroll me for the first time and, if necessary, transfer my existing records rather than classifying me as a new subscriber.

14I understand that I have to tell my internet company within 30 days if I do not qualify for the 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.

15I 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.

16I 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.

17For my household, I affirm and understand that the ACP is a 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 company’s undiscounted general rates, terms, and conditions if my household continues to subscribe to the service.

18All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.

19I 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.

Leave this empty:

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Signature Certificate
Document name: Werks Mobile
lock iconUnique Document ID: d065fb4c2b400f55d82877a20f7f59d921cbf81b
Timestamp Audit
January 12, 2024 7:00 am EDTWerks Mobile Uploaded by Omar Lloyd - olloyd@werksmobile.com IP

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