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Lifeline and Affordable Connectivity Program (ACP) Enrollment Applications

Lifeline and the Affordable Connectivity Program (ACP) are separate programs. Lifeline benefits may be combined with ACP benefits and applied to the same service plan. You may also apply Lifeline and ACP benefits to different service plans. You do not need to enroll in Lifeline in order to enroll in ACP and you do not need to enroll in ACP in order to enroll in Lifeline. You may choose to get Lifeline and ACP services from different service providers. You may transfer your Lifeline and ACP services to another provider subject to certain regulatory restrictions.

Completion of this form is required. This form is used for the purpose of verifying your eligibility for and enrolling you in Lifeline and ACP benefits and an eligible American Assistance service plan and will not be used for any other purpose. Lifeline and ACP benefits are subject to verification of eligibility by American Assistance and the National Verifier. If you wish to enroll in only Lifeline or only the ACP with American Assistance, you may do so by using either the separate Lifeline Enrollment Application or ACP Enrollment Application. Lifeline and ACP services are subject to availability and American Assistance’s Terms and Conditions and Policies available at www.AmericanAsistance.com.

Personal Information:

First Name: CINDY Middle Name: LASHAWN Last Name: LUMPKIN DOB Month: FEBRUARY Day: 25 Year: 1981 Last Four SSN (or Tribal ID#): 0357 Residential Address (May not be a PO Box) Contact Number (if available): Street address: 705 SPRING VALLEY RD Apt: Lot 161

City: ATHENS State: GA Zip Code: 30605

This address is (choose one): Permanent Temporary

Billing Address (if different from Above) (P.O. Box is permitted) Street address: Apt:

City: State: Zip Code:

Service activation and usage requirement:

American Assistance service is a prepaid service offered by the company to subscribers eligible for Lifeline and/or ACP discount benefits in states where it is authorized to do so. To maintain your service and benefits, you must personally activate the service by placing a call, initiating data usage, or by responding to instructions from American Assistance to activate the service. To keep your account active, you must use the service at least once during any 30-day period by completing an outbound call, sending a text message, using cellular data, purchasing additional service from American Assistance, answering an in-bound call from someone other than American Assistance, or by responding to a direct contact from American Assistance confirming that you want to continue receiving service from American Assistance. If your service goes unused for 30 days, you will no longer be eligible for Lifeline or ACP benefits (or both, if you choose to apply both benefits to the same service) and your service may be suspended (allowing only 911 calls and calls to the American Assistance's customer care center) 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, keep your telephone number and remain enrolled in Lifeline and ACP, as applicable.

I hereby certify that I have read and understood the disclosures listed above regarding activation and usage requirements. Lifeline Application, Disclosures, Authorizations and Certifications Lifeline is a government benefit program operated by the Federal Communications Commission (FCC) that provides discounts on monthly broadband Internet access service and/or voice service. For more information about Lifeline and program eligibility requirements, call us at 1-877-***-**** or visit www.AmericanAssistance.com/lifeline (www.AmericanAssistance.com). Willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the Lifeline program.

Only one Lifeline benefit is available per household. A household is not permitted to receive discounted Lifeline services from multiple providers. A household is defined, for purposes of the Lifeline program, as any individual or group of individuals who live together at the same address and share income and expenses. Violation of the one-per-household limitation constitutes a violation of the FCC's rules and will result in you being de-enrolled from the Lifeline program. Lifeline discount benefits are not transferrable to other households or persons. Eligibility for Lifeline is determined by the National Verifier and National Lifeline Accountability Database, administered by the Universal Service Administrative Company (USAC), or an alternative verification process approved by the FCC. American Assistance’s complete Terms and Conditions, including our Acceptable Use and Privacy Policies, apply and are available at www.AmericanAssistance.com.

I hereby certify that I have read and understood the disclosures listed above regarding Lifeline benefits and consent to enroll in Lifeline with American Assistance.

I authorize and give express consent for American Assistance and its contracted partners to contact me to validate my eligibility for, desire to participate in, or subscription to American Assistance’s Lifeline offers and other products and services via email, telephone, or text messaging, including calls using an automated telephone dialing system, manually, or with pre-recorded/artificial voice messages. Text messaging and data rates may apply. Consent for emails, calls and texts is optional and can be revoked at any time by dialing 611 from my American Assistance provided wireless number or by calling 1-877-***-**** and revoking consent. However, I understand that opting out will not affect American Assistance's ability to contact me with notices and messages regarding Lifeline and/or any other service or product via the methods listed herein. For more information see our Terms and Conditions and Privacy Policy at www.AmericanAssistance.com I acknowledge that I am providing the information I have included in this form to CGM, LLC and further authorize CGM, LLC to receive and use my information for enrollment verification and waste, fraud, and abuse mitigation purposes. I also authorize CGM to receive and use my historic Lifeline enrollment information for verification and waste, fraud, and abuse mitigation purposes.

Lifeline Eligibility Criteria and Electronically Initialed Certifications: Program eligibility: Supplemental Nutrition Assistance Program (SNAP/Food Stamps/Food Assistance) program You must acknowledge each of the certifications below individually and under penalty of perjury: I meet the income-based or program-based eligibility criteria for Lifeline in FCC rule 47 C.F.R. § 54.409; I will notify American Assistance within 30 days if for any reason I no longer satisfy the criteria for receiving Lifeline including, as relevant, if I no longer meet the income-based or program-based criteria for receiving Lifeline support, I am receiving more than one Lifeline benefit, or another member of my household is receiving a Lifeline benefit; If I am seeking to qualify for Lifeline as an eligible resident of Tribal lands, I live on Tribal lands, as defined in FCC rule 47 C.F.R. 54.400(e);

If I move to a new address, I will provide that new address to American Assistance within 30 days; My household will receive only one Lifeline service and, to the best of my knowledge, my household is not already receiving a Lifeline service;

The information contained in this certification form is true and correct to the best of my knowledge; I acknowledge that providing false or fraudulent information to receive Lifeline benefits is punishable by law; and I acknowledge that I may be required to re-certify my continued eligibility for Lifeline at any time, and my failure to re-certify my continued eligibility will result in de-enrollment and the termination of my Lifeline benefits pursuant to FCC rule 47 C.F.R. § 54.405(e)(4).

I authorize American Broadband and its contracted partners, for the purpose of applying for, determining eligibility, enrolling in and seeking reimbursement of Lifeline benefits, to collect, use, share, and retain my personal information, including but not limited to information required for the purpose of establishing eligibility for and enrolling in the Lifeline program, and 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 information necessary to establish identity and verifiable address. This information may be shared with Universal Service Administrative Company (USAC) to ensure proper administration of the Lifeline program. Failure to provide consent will result in me being denied Lifeline benefits and service. Lifeline Benefit Transfer Consent:

A subscriber already enrolled in Lifeline with another provider must consent to the transfer of their Lifeline benefit to American Assistance.

The effect of a Lifeline benefit transfer is that your Lifeline benefit will be applied to American Assistance’s Lifeline service 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. After receiving and reviewing the foregoing required disclosures, I consent to and authorize American Assistance to transfer my current Lifeline benefit to American Assistance, if I am found to already be receiving a Lifeline discount benefit from another Lifeline provider.

ACP Disclosures, Authorizations and Certifications The Affordable Connectivity Program (ACP) is a government benefit program operated by the Federal Communications Commission

(FCC) that provides discounts on monthly broadband Internet access service and certain connected devices. For more information about the ACP and program eligibility requirements, call us at 1-877-***-**** or visit www.AmericanAssistance.com/acp. Willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the program.

ACP benefits may be obtained from any participating provider of your choosing and your monthly service benefit may be transferred to another provider no more than once in a service month. ACP discounts can be applied to any available American Assistance service plans at the same terms available to households that are not eligible for ACP supported services. Upload/download speeds will be determined by your particular service plan, and other factors, including your device, network availability from our underlying carrier, your proximity to cellular towers, and environmental factors may affect speeds, as described in our Broadband Transparency Disclosure at www.AmericanAssistance.com. A complete listing of our plans, including plans that are fully covered (no co-pay after application of the ACP discount), is available at www.AmericanAssistance.com/acp/plans.

American Assistance’s complete Terms and Conditions, including the Acceptable Use Policy, Privacy Policy and ACP Terms and Conditions, apply and are available at www.AmericanAssistance.com. ACP monthly service and one-time device discounts are not transferrable to other households or individuals. An eligible household is limited to one monthly service discount and a single one-time device discount. An eligible household does not have to purchase an ACP discounted connected device in order to enroll in the ACP and receive monthly service discounts. Devices available for ACP discounts are listed at www.AmericanAssistance.com/ACP/devices. Eligibility for the ACP is determined by the National Verifier and National Lifeline Accountability Database, administered by the Universal Service Administrative Company (USAC), or an alternative verification process approved by the FCC. Your ACP discount benefit is separate from your Lifeline discount benefit. Your household can receive only one ACP benefit and one Lifeline benefit. Your ACP benefit can be separate or combined with your Lifeline benefit, depending on your choice and the service plan you choose. Lifeline participants may maintain their existing Lifeline services without enrolling in the ACP and may choose to take ACP benefits from another service provider.

If the FCC announces the end of the ACP, we discontinue our ACP service offers, you transfer your ACP benefits to another provider, or we determine your household is no longer eligible, we will notify you and you will revert to receiving the standard FREE Lifeline plan where available and if you are enrolled in Lifeline with American Assistance and remain eligible. You may keep your service plan by paying the applicable undiscounted rate plus applicable fees and taxes. If you select a plan that is not fully covered by applicable discounts and requires monthly post-payments (American Assistance does not offer any such plan at this time), American Assistance may disconnect your ACP-supported service after 90 consecutive days of non-payment.

A household may file a complaint against an ACP service provider via the FCC’s Consumer Complaint Center. I hereby certify that I have read and understood the disclosures listed above regarding the ACP benefits and consent to enroll in the ACP with American Assistance.

If I am seeking to qualify for ACP benefits as an eligible resident of Tribal lands, I certify that I live on Tribal lands, as defined in FCC rule 47 C.F.R. 54.400(e).

I authorize and give express consent for American Assistance and its contracted partners to contact me to validate my eligibility for, desire to participate in, or subscription to American Assistance’s ACP offers and other products and services via email, telephone, or text messaging, including calls using an automated telephone dialing system, manually, or with pre-recorded/artificial voice messages. Text messaging and data rates may apply. Consent for emails, calls and texts is optional and can be revoked at any time by dialing 611 from my American Assistance provided wireless number or by calling 1-877-***-**** and revoking consent. However, I understand that opting out will not affect American Assistance's ability to contact me with notices and messages regarding ACP service and connected device benefits and/or any other service or product via the methods listed herein. For more information see our Terms and Conditions and Privacy Policy at www.AmericanAssistance.com.

I acknowledge that I am providing the information I have included in this form to CGM, LLC and further authorize CGM, LLC to receive and use my information for enrollment verification and waste, fraud, and abuse mitigation purposes. I also authorize CGM to receive and use my historic Emergency Broadband Benefit and ACP enrollment information for verification and waste, fraud, and abuse mitigation purposes.

I agree that any state, local, Tribal government, school, or school district, may share information about my receipt of benefits that would establish eligibility for the ACP, and that such information will be used only to determine ACP eligibility. I certify that if I receive a connected device discount from American Assistance as part of the ACP, I will pay a minimum of

$10.01 and a maximum of $49.99 for the connected device and that, to the best of my knowledge, no one in my household has received a connected device discount from any service provider through the ACP or the Emergency Broadband Benefit program.

I authorize American Broadband and its contracted partners, for the purpose of applying for, determining eligibility, enrolling in and seeking reimbursement of ACP service and connected device benefits, to collect, use, share, and retain my personal information, including but not limited to information required for the purpose of establishing eligibility for and enrolling in the ACP program, and 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 ACP service discount was initiated and if applicable, terminated, usage status and other compliance requirements, the amount of support being sought for the service, and information necessary to establish identity and verifiable address. This information may be shared with Universal Service Administrative Company (USAC) to ensure proper administration of the ACP program. Failure to provide consent will result in me being denied ACP service and connected device benefits. ACP Benefit Transfer Consent:

A subscriber already enrolled in the ACP with another provider must consent to the transfer of their ACP benefit to American Assistance.

The effect of an ACP benefit transfer is that your ACP benefit will be applied to American Assistance’s ACP service and will no longer be applied to service retained from your former ACP service provider. You may be subject to your former ACP provider’s undiscounted rates as a result of the transfer if you elect to maintain service from that provider. You are limited to one ACP 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. After receiving and reviewing the foregoing required disclosures, I consent to and authorize American Assistance to transfer my current ACP benefit to American Assistance, if I am found to already be receiving an ACP discount benefit from another ACP provider.

By checking this box, I hereby certify, under penalty of perjury, that the information included in the foregoing applications and certifications is true and correct to the best of my knowledge. I consent to use of this electronic form. I understand I have the right to enroll in the service using non-electronic methods. I further understand that I have the right to withdraw this consent at any time prior to the activation of my service. American Assistance has advised me and I understand that I may request a paper copy of my contractual terms and associated fees or withdraw this consent by calling 1-877-***-****.

Applicant's Signature: Cindy LaShawn Lumpkin Date: 05/01/2022 05:35 AM Version: 1.2

Release Date: 4/15/2022

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