ACP Customer Disclosure Affordable Connectivity Program Customer Disclosures For customers of NEMR TelecomThe Affordable Connectivity Program is a government program intended to make broadband services and connected internet devices affordable for low-income households. The program provides a monthly discount of up to $30 for eligible households and $75 for eligible Tribal households. The program also supports a one-time connected internet device of up to $100 for service providers that choose to offer a device.In order to qualify for the program, eligible consumers must be enrolled in a qualifying program that includes: Medicaid, Supplemental Nutrition Assistance Program, WIC Program, Supplemental Security Income, Federal Public Housing Assistance, Veterans and Survivors Pension Benefit, Bureau of Indian Affairs General Assistance, Tribally-Administered Temporary Assistance to Needy Families, Tribal Head Start, Food Distribution Program on Indian Reservations, is approved for the free or reduced price school breakfast/lunch program (including through the USDA Community Eligibility Provision), received a federal Pell Grant, or have income at or below 200% of the Federal Poverty Guidelines. NEMR Telecom 718 S West St, PO Box 98 Green City, MO 63545 660-874-4111 Name(Required) First Last (Print First and Last Name) stating you understand the following (please initial each statement below):D.O.B.(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Last Four of SSN(Required) Contact Phone(Required)Email(Required) -Please initial each statement below acknowledging your consent-*The Affordable Connectivity Program is a U.S. government program that reduces my monthly internet bill.(Required) *I may choose to participate in the Affordable Connectivity Program from any participating service provider.(Required) *I may apply the Affordable Connectivity Program benefit to any broadband service offering of NEMR at the same terms available to households that are not eligible for the same Affordable Connectivity Program-supported service.(Required) *My Affordable Connectivity Program-service may be disconnected after 90 consecutive days of non-payment.(Required) *I will be subject to NEMR’s undiscounted rates and general terms and conditions if the Affordable Connectivity Program ends, or if I transfer my Affordable Connectivity Program benefit but continue to receive service from NEMR, or upon de-enrollment from the Affordable Connectivity Program.(Required) *I may file a complaint against NEMR via the FCC Consumer Complaint Center.(Required) *I understand that I am not required to accept a connected-device to enroll in the Affordable Connectivity Program.(Required) * I have been made aware of all NEMR service plans that are fully covered by the Affordable Connectivity Program.(Required) *I consent to enroll into the Affordable Connectivity Program with NEMR.(Required) SignatureDate MM slash DD slash YYYY NEMR Telecom is an equal opportunity provider and employer.