Emergency Broadband Benefit Program (EBBP) Opt-In Form

Date

Customer Name

Address

City

State

Zip Code

Telephone Number

Mobile Number

Email Address

Please read and initial each of the following to participate in the EBB Program:

I hereby opt-in to the Emergency Broadband Benefit Program (EBBP).

I acknowledge that I am aware of the eligibility requirements for the EBB Program.

I acknowledge that the EBB Program is non-transferable and that the discount is limited to one EBB discount per household, and I further certify that no other member of my household is receiving an emergency broadband benefit under the EBBP.

I acknowledge that I have reviewed the available upload/download speeds for services offered by Citizens Telephone Cooperative (dba Citizens) for the EBB Program.

I acknowledge that the EBB Program is a temporary emergency federal government benefit program operated by the Federal Communications Commission and, upon the conclusion of the benefit, my household will be subject to Citizens’ regular rates, terms, and conditions which is expected to be $0 per month, if my household continues to subscribe to Citizens’ broadband service or standard rate selected should I upgrade during the term of the EBB program.

I consent to applying my EBB program benefit to the broadband Internet access service I receive from Citizens.

I consent to Citizens disclosing and/or transmitting any information required to the program Administrator for my participation in the program including but not limited to my name, my dependent’s name, date of birth, last 4 digits of social security number or Tribal Identification Number, address, telephone number, type of service, start date of service, termination of service date, EBB Program discount amount, eligible program, tribal benefit status, Lifeline Tribal Benefit, Linkup Service Date and Independent Economic Household certification date.

I consent to Citizens verifying my household’s broadband usage each month to enable Citizens to claim reimbursement for my program benefit each month.

I acknowledge that if Citizens has a reasonable basis to believe that I am no longer eligible to receive the EBBP benefit, I will receive a notification of impending termination of my EBBP benefit and will have 30 days following the date of such notice to demonstrate continued eligibility.

I acknowledge that I may obtain EBB-supported broadband service from any participating provider of my choosing and that I can transfer their Emergency Broadband Benefit to another provider at any time.

I acknowledge that if I cannot demonstrate eligibility, I will not be enrolled in the program and/or Citizens is required to de-enroll me from the program.

I acknowledge that I will not be required to pay early termination fees if I choose to terminate or modify my broadband service during my participation in the EBBP, or upon receiving notice of the benefit ending.

I acknowledge that my participation in the EBBP does not relieve my obligations to adhere to Citizens’ posted rates, terms and conditions, or other rules and regulations or tariffs that govern the services I receive.

I acknowledge that the Emergency Broadband Benefit will not be prorated for a partial month of service and may be less than the full benefit during the final month of the program when program funding is nearing depletion.

I certify that:
(1) I have confirmed my eligibility for the Emergency Broadband Benefit Program through the National Verifier.