Tribal Identification Number will be accepted if no social security number. You can select alternate Id check box if you have Identity Proof other than SSN & TribalId
ELIGIBILITY
CHILD OR DEPENDENT INFORMATION
Tribal Identification Number will be accepted if no social security number. You can select alternate Id check box if you have Identity Proof other than SSN & TribalId
Completion of this form is required. This form is used for the purpose of verifying your eligibility for and enrolling you in Lifeline Program benefits and to apply an eligible IPC service plan and will not be used for any other purpose. Lifeline benefits are subject to verification of eligibility by IPC and the National Verifier.
Lifeline services are subject to availability and IPC’s Terms and Conditions and Policies available at
www.ipcclec.com.
Provider Name: Integrated Path Communications LLC
Effective Date:02/12/2025
Applicant Information:
Residential Address
Residential Address (may not be a PO box):
Service Activation and Usage Requirements:
Integrated Path Communications, LLC (IPC) service is a prepaid service offered by the company to subscribers eligible for Lifeline discount benefits in states where it is authorized to do so. To maintain your service and benefits, you must personally activate the service by initiating data usage, or by responding to instructions from IPC to activate the service. To keep your account active, you must use the service at least once during a 30-day period by completing an outbound call, sending a text message, using cellular data, purchasing additional service from IPC, answering an inbound call, or responding to a direct contact from IPC confirming your intent to continue receiving service.
If your service goes unused for 30 days, you will no longer be eligible for program benefits and your service is subject to a 15-day cure period during which you must use the service (as described above) in order to fully re-activate your service and remain enrolled in the Lifeline Program.
Lifeline Disclosures, Authorizations, and Certification:
Program Eligibility Verification: I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that the Lifeline Program is a government assistance program that provides a discount on telecommunications services to eligible low-income households.
One Lifeline Benefit per Household: I confirm that my household does not currently receive more than one Lifeline benefit. I agree to notify IPC or the Lifeline Program Administrator immediately if I or anyone in my household receives a second Lifeline benefit.
Use of Information: I consent to IPC and the Lifeline Program Administrator using the information I provide to:
Verify my eligibility through federal and state databases.
Confirm my continued participation in qualifying programs, if applicable.
Comply with Lifeline Program rules and audits.
Annual Recertification: I understand that I must annually recertify my continued eligibility for Lifeline benefits and may be required to respond to requests for documentation. Failure to do so may result in the loss of Lifeline benefits.
Acknowledgment of Responsibilities: I acknowledge that I am responsible for notifying IPC of any changes in my eligibility status, including:
Changes to my qualifying program participation.
A move to a new address.
The addition of another Lifeline benefit to my household.
Penalties for Misrepresentation: I understand that providing false or fraudulent information to receive Lifeline benefits is punishable by law and may result in fines, imprisonment, and removal from the program.
Authorization: I authorize IPC and its contracted partners, for the purpose of applying for, determining eligibility, enrolling in and seeking reimbursement of Lifeline service and device benefits, to collect, use, share, and retain my personal information, including, but not limited to, full name, full residential address, date of birth, last four digits of social security number, telephone number, eligibility criteria and status, the date on which the Lifeline service discount was initiated and, if applicable, terminated, usage status, and other compliance requirements, the amount of support being sought for the service and/or device, and information necessary to establish identity and verifiable address, to USAC to ensure proper administration of the Lifeline service and/or connected device benefits. Failure to provide consent will result in me being denied the Lifeline service benefits.
Privacy Notice:
IPC values your privacy. Your information will be handled in accordance with federal and state regulations and used solely for Lifeline enrollment and compliance purposes. For more details on our privacy policy, please visit
Privacy-policy.
Lifeline Benefit Transfer Consent:
A subscriber already enrolled in the Lifeline program with another provider must consent to the transfer of their Lifeline benefit to IPC.
The effect of a Lifeline benefit transfer is that your Lifeline benefit will be applied to IPC program services and will no longer be applied to service retained from your former Lifeline service provider. You may be subject to your former Lifeline provider's undiscounted rates as a result of the transfer, if you elect to maintain service from that provider.
You are limited to one Lifeline benefit transfer transaction per service month, with limited exceptions for situations where a subscriber seeks to reverse an unauthorized benefit transfer or is unable to receive service from a specific provider.
Enrollment Consent:
Applicant’s Signature:
Digitally signed by:
[Full Name]
Date:
National Verifier
Thank you for submitting your information.
Lifeline Status:
ACP Status:
Order ID :
Application ID :
Plans/Devices
Order ID :
Plans:
Devices:
Enroll
Congratulations!
Your Lifeline enrollment has been approved.
Order ID :
Lifeline Status:
Please stand-by, a preactivate SIM will be shipped to you within 2 to 3 business days. It will take 7 to 8 business days to deliver to your address. For more information, please email us at support@ipcclec.com or call us at 833-778-0321
Order ID :
Lifeline Status:
Congratulations!
Your ACP enrollment has been approved!
To finish your order, click Payment below to process your $11.00 payment for your new tablet.
Once your payment has been received, your tablet will be shipped within 1-2 business days.
Order Summary!
Order ID:
Plan: $
Device: $
Total Amount: $
Click the Payment button to complete the payment.
Congratulations!
Your order was successful and a request was placed for shipment.
Below are the order details:
Order ID:
Plan:
Device:
A will be shipped to you within 2 to 3 business days. It will take 7 to 8 business days to deliver to your address. For more information, please email us at support@ipcclec.com or call us at 833-778-0321
Payment was failed. .
Payment
Our customer support will reach you in 24 hours to collect the payment.
Transfer Exception Form
About the ACP
The ACP is a Federal Communications Commission (FCC) program that provides a monthly internet service discount and a one-time connected device benefit from participating internet companies for qualifying low-income consumers.
What is this worksheet for?
Use this worksheet if you need to transfer your Affordable Connectivity Program
(ACP) benefit, but have been told that you need an exemption to make an
additional transfer in this calendar month.
Please check the appropriate statement if one of the exceptions below applies
to your household:
By signing, you agree that the information you provided on this form is true and
correct to the best of your knowledge.