Enrollment form for Affordable Connectivity Program Name * First Name Last Name Date of Birth * MM DD YYYY Last 4 of SSN * Tribal ID Tribal Identification Number will be accepted if no social security number. Phone * (###) ### #### Email * Eligibility * Federal Public Housing Food Stamps Household Income Medical Assistance (Medicaid) Supplementary Security Income (SSI) Tribally-Administered Temporary Assistance for Needy Families (TTANF) Tribal Head Start (Income Qualifying Only) Tribal - Food Distribution Program on Indian Reservations (FDPIR) Tribal - Bureau of Indian Affairs General Assistance Program Eligibility Approved by State Administrator Veteran's Pension CEP/School Lunch/Breakfast Program Federal Pell Grant Substantial Loss of Income Existing Low Income Program Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Who Receives the Benefit? * Myself Child or Dependent in Household Address Address 1 Address 2 City State/Province Zip/Postal Code Country Thank you!
