ACP Benefit Transfer ACP Benefit TransferI hereby authorize the transfer of my ACP benefit to Northeast Missouri Rural Telephone Company (NEMR). I give permission for NEMR to initiate the transaction in NLAD on my behalf to transfer said benefit to NEMR.1) I consent to transfer my ACP benefit to NEMR.2) I understand that by transferring my ACP benefit to NEMR, I will no longer be able to apply the ACP benefit to the service provider that my ACP benefit currently applies to.3) I understand that I will be subject to the undiscounted rates for my current ACP supported service provider.4) I understand that I am limited to one ACP-transfer per service month with limited exceptions.5) I understand all of the disclosures listed on this document.My signature below is proof of consent to the above transaction rules. NEMR 718 S West St, PO Box 98 Green City, MO 63545 660-874-4111 Name(Required) First Last Date MM slash DD slash YYYY Contact Phone(Required)D.O.B.(Required) MM slash DD slash YYYY Last Four of SSN(Required) Signature Reset signature Signature locked. Reset to sign again
