AT&T

 

for any other purpose. PLEASE PRINT USING BLOCK CAPITAL

LETTERS IN BLACK OR BLUE INK ONLY.

When completed, please mail both the form and copies of proof of eligibility to: Access from AT&T, PO Box 789, Killeen, TX 76540. For faster

review and approval of Access from AT&T, apply and upload your documents at att.com/access.

hemalshahusa@gmail.com ✘

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THE FOLLOWING DOCUMENTATION MUST BE ATTACHED TO PROCESS THE APPLICATION

PHOTOCOPY (original documentation will not be returned) one or more of the following documents and submit with this application:

If your application is based on SNAP Participation:

By signing this application, I certify that: I have read and understand the facts stated above; I, or a member of my household, participates in at least one

of the Access from AT&T Qualifying Programs; and that the information and documentation provided in this application are true and correct.

Applicant’s Signature: Date:

Benefit

Qualifying Person’s Signature: Date:

(If different than applicant)

How did you hear about this program? (Check all that apply.)

School District Radio, Television, or Print Advertisement

State or Community Organization or Event Mail or E-Mail

National Organization Friend or Relative

EveryoneOn Website or Event I am a HUD, public housing or Section 8 resident

©2024 AT&T Intellectual Property. All rights reserved. AT&T and Globe logo are registered trademarks of AT&T Intellectual Property.

05/30/2024 Need help? Check the FAQs or start an online application at https://att.com/access.

CERTIFICATION

In addition to accepting the High Speed Internet Terms of Service during the service registration process, the Access from AT&T program requires you

to certify that you or a member of your household participates in at least one of the Qualifying Programs, that the information and documentation you

have provided in this application is true and correct, and that you have read and agree to the following additional terms of service:

Access from AT&T is a program to provide low-cost wireline home Internet service to qualifying households with at least 1 resident who participates

in at least one of Qualifying Programs with an address in AT&T’s 21-state service area at which AT&T offers wireline home Internet service

Low-cost wireline home internet service availability and speed may vary by address. Go to att.com/access for more information.

At least one individual participating in a Qualifying Program must continue to reside in the qualifying household during the period the Access

from AT&T service is in effect.

One discounted wireline Internet connection is allowed per household. (A qualifying household includes everyone who lives at your address,

including children and people who are not related to you).

(APPLICATION FOR LOW-COST WIRELINE HOME INTERNET SERVICE)

ACCESS FROM AT&T

• A SNAP card showing the name of the SNAP participant.

If you are a California resident and your application is based on SSI benefits:

• A current benefit verification letter confirming that a resident of your household has qualified for SSI benefits.

If your application is based on National School Lunch Participation:

• A current award letter showing the name and address of the student.

If your application is based on Households with income 200% or less than the federal poverty guidelines:

• A copy of most current SSA1099, W-2 or Social Security statement of benefits

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