MAXSIP Free Internet Signup maxsip Step 1 of 5 20% Which service would you like to apply for?(Required)Select a qualifying program4G Tablet With Internet (Valued at $300) & Free Monthly Service ($20 one time fee will apply)Mobile Hotspot With Free Monthly Service ($50 one time fee will apply)Third ChoiceSmart Phone With Free Monthly Service ($70 one time fee will apply)BRING YOUR OWN DEVICE - 4G SIM Card that will give you Data, Talk, and Text for FREE (You need a SIM card compatible device) - $015GB Data Monthly for the TabletWhat is your full legal name?The name you use on official documents, like your Social Security Card or State ID. Not a nickname.First Name(Required) Last Name(Required) What is your date of birth?(Required) MM slash DD slash YYYY You must be over 18 to apply for this program. If your child qualifies and not you, apply under your name and add the child name under the child section.Last 4 digits of your SSN(Required) Executive Number(Required) Your Phone Number(Required)Please enter a number from 1000000000 to 9999999999.Please leave out the 1 before the number. Don't add dashesEmail(Required) This is how we will communicate with you if we require more information. Please keep an eye on your email as additional documentation may be required. Verify Email(Required) This is how we will communicate with you if we require more information. Please keep an eye on your email as additional documentation may be required. House Number(Required) Street Address(Required) This is where we will ship your device.Apt # City(Required) States(Required)AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code(Required) If you do not qualify on your own (such as if your child qualifies through the Free School Lunch Program), you can sign up for Lifeline or the Emergency Broadband Benefit through your child or dependent if they participate in any of the qualifying programs. How do I qualify?(Required) I qualify for the program on my own I ONLY qualify through my child or dependent Your household qualifies for the Benefit if you OR any member of the household: Qualifies for Lifeline benefits through participation in SNAP, Medicaid, Supplemental Security Income, Federal Public Housing Assistance, or Veterans and Survivors Pension Benefit Received approval for benefits under the free and reduced-price school lunch program or the school breakfast program, including through the USDA Community Eligibility Provision, in the 2019-2020 or 2020-2021 school year Experienced a substantial loss of income since February 29, 2020 due to job loss or furlough AND has a total household income in 2020 at or below $99,000 for single filers and $198,000 for joint filers Received a federal Pell Grant in the current award year Meets the eligibility criteria for a participating provider's existing low-income or COVID-19 program, and that provider received FCC approval for its eligibility verification process It has an income at or below 200% of the federal poverty guidelines Participates in one of several Tribal specific programs: Bureau of Indian Affairs General Assistance, Tribal Head Start (only households meeting the relevant income qualifying standard), Tribal Temporary Assistance for Needy Families (Tribal TANF), Food Distribution Program on Indian Reservations What is their full legal name?We will use your Child or Dependent's Information to find out if you qualify for the Lifeline Program or the Emergency Broadband Benefit Program through them.First Legal Name(Required) Last Legal Name(Required) Date of Birth(Required) MM slash DD slash YYYY What is their last 4 digits of SSN?(Required) Check How You Want to Qualify(Required) Medicaid Free and Reduced Price School Lunch Program or School Breakfast Program in the 2019-2020 or 2021-2022 school year SNAP (Supplemental Nutrition Assistance Program) or Food Stamps Supplemental Security Income (SSI) Federal Public Housing Assistance Veterans Pension and Survivors Benefit Programs Federal Pell Grant in the current award year Experienced a substantial loss of income due to job loss or furlough, since February 29, 2020 Tribal Specific Program (only choose if you live on Tribal lands) I don't participate in one of these programs, I want to qualify through my income To qualify for the Free Internet Benefit, we need to know which government assistance program you are in. You will be asked to submit documents about the program(s) you select. To prove participation in one of the above programs, you must submit a document that, at minimum, includes: Your name, or your dependent's name The name of the qualifying program, such as Medicaid The government or Tribal program administrator or the managed care organization (MCO) that issued the document An issue date within the last 12 months or a future expiration date that aligns with the benefit period Example: Benefit Card, letter from qualifying program containing your information and expiration dates, screenshot from Medicaid app. Your documents must have a printed date or expiration date on it.You will be asked to submit documents about the program(s) you select. To prove participation in one of the above programs, you must submit a document that, at minimum, includes: Your name, or your dependent's name The name of the qualifying program, such as Medicaid The government or Tribal program administrator or the managed care organization (MCO) that issued the document An issue date within the last 12 months or a future expiration date that aligns with the benefit period Example: Benefit Card, letter from qualifying program containing your information and expiration dates, screenshot from Medicaid app. Your documents must have a printed date or expiration date on it.You will be asked to submit documents about the program(s) you select. To prove participation in one of the above programs, you must submit a document that, at minimum, includes: Your name, or your dependent's name The name of the qualifying program, such as Medicaid The government or Tribal program administrator or the managed care organization (MCO) that issued the document An issue date within the last 12 months or a future expiration date that aligns with the benefit period Example: Benefit Card, letter from qualifying program containing your information and expiration dates, screenshot from Medicaid app. Your documents must have a printed date or expiration date on it.You will be asked to submit documents about the program(s) you select. To prove participation in one of the above programs, you must submit a document that, at minimum, includes: Your name, or your dependent's name The name of the qualifying program, such as Medicaid The government or Tribal program administrator or the managed care organization (MCO) that issued the document An issue date within the last 12 months or a future expiration date that aligns with the benefit period Example: Benefit Card, letter from qualifying program containing your information and expiration dates, screenshot from Medicaid app. Your documents must have a printed date or expiration date on it.You will be asked to submit documents about the program(s) you select. To prove participation in one of the above programs, you must submit a document that, at minimum, includes: Your name, or your dependent's name The name of the qualifying program, such as Medicaid The government or Tribal program administrator or the managed care organization (MCO) that issued the document An issue date within the last 12 months or a future expiration date that aligns with the benefit period Example: Benefit Card, letter from qualifying program containing your information and expiration dates, screenshot from Medicaid app. Your documents must have a printed date or expiration date on it.To prove participation, submit one of the following acceptable documents: Written confirmation from a student's Institution of Higher Education or the Department of Education that the student has received a Pell Grant for the current award year A student's official financial aid award letter documenting the amount of a students' Pell Grant award received for the current award year A copy of a student's paid invoice that clearly documents the student's receipt of a Pell Grant during the current award year A copy of a student's Student Aid Report that clearly documents the student's receipt of a Pell Grant during the current award year Screenshot of student dashboard from National Student Loan Data System, for the current award year Screenshot from FAFSA, for the current award year A copy of the email notification from the Department of Education sent to all Pell Grant recipients about the EBB program, for the current award year The document must include: Your name, or your dependent's name Name of program administrator or University/College that issued the document A current award year Enter your (or your dependent's) School, University or College(Required) To qualify for the Emergency Broadband Benefit based on a substantial loss of income since February 29, 2020, your household income for 2020 must be no greater than $99,000 for single filers or $198,000 for joint filers. To demonstrate a substantial loss of income since February 29, 2020, submit one of the acceptable documents from BOTH Group 1 and Group 2 below: Group 1 (Proof of loss of job - dated on or after February 29, 2020) Layoff notification or furlough notice from Employer Approval Letter of unemployment Unemployment Benefit Statement Application for unemployment benefits Group 2 (Proof that the household does not have an income greater than $99,000 for single filers and $198,000 for joint filers for calendar year 2020.) 2020 state, federal, or Tribal tax return (e.g., W2 or 1040) A Social Security statement of benefits A Veterans Administration statement of benefits A retirement/pension statement of benefits Unemployment/worker's compensation statement of benefit Divorce decree, child support award, or other official document containing income information The document must include: Your name, or your dependent's name 2020 calendar year income information (gross income annualized) How many people live in your household?(Required) To prove participation in one of the above programs, you must submit a document that, at minimum, includes: Your name, or your dependent's name The name of the qualifying program, such as Medicaid The government or Tribal program administrator or the managed care organization (MCO) that issued the document An issue date within the last 12 months or a future expiration date that aligns with the benefit period Which Tribal specific programs do you have?(Required) Bureau of Indian Affairs General Assistance Tribally-Administered Temporary Assistance for needy Families (TTANF) Food Distribution Program on Indian Reservations (FDPIR) Head Start (only if your household meets the Head Start income quality standard) Tribal ID(Required) To prove your household income is at 135% or less of the Federal Poverty Guidelines, you must submit one or more of the following documents (screenshot or picture is ok): The prior year's state, federal, or Tribal tax return Current income statement from an employer or paycheck stub A Social Security statement of benefits An Unemployment or Worker's Compensation statement of benefits A Federal or Tribal notice letter of participation in General Assistance A Divorce Decree, child support award, or other official document containing income information Note: If the document doesn't cover a full year, such as a pay stub, you must show the same document for (3) months in a row within the same year to provide your gross annual income. Agree to All The information you gave us will be used to check if you qualify for the Emergency Broadband Benefit. Please confirm that it is okay.(Required) By checking this box you are consenting that all of the information you providing may be collected, used, shared, and retained for the purpose of applying for and/or receiving the Free Internet Program (Required) I live at an address with more than one household. If you live alone or you live with other adults who do not receive Lifeline or the Emergency Broadband Benefit, do not initial this box. (Required) I understand I am only allowed to get one Lifeline benefit and one Emergency Broadband Benefit (if applicable) per household, not per person. (Required) I understand that this limit is an FCC rule, and lying about my household on this government form can make me lose my Lifeline benefit or my Emergency Broadband Benefit and is against the law. I agree, under penalty of perjury, to the following statements(Required) I agree that if I move I will give my service provider my new address within 30 days. (Required) I understand that I have to tell my service provider within 30 days if I do not qualify for Lifeline anymore, including: Initial I, or the person in my household that qualifies, do not qualify through a government program or income anymore. 1. Either I or someone in my household gets more than one Lifeline benefit (including, more than one Lifeline broadband internet service, more than one Lifeline telephone service, or both Lifeline telephone and Lifeline broadband internet services). (Required) I know that my household can only get one Lifeline benefit and, to the best of my knowledge, my household is not getting more than one Lifeline benefit. (Required) I agree that my service provider can give the Lifeline Program administrator all of the information I am giving on this form. I understand that this information is meant to help run the Lifeline Program and that if I do not let them give it to the Administrator, I will not be able to get Lifeline benefits. (Required) All the answers and agreements that I provided on this form are true and correct to the best of my knowledge. (Required) I know that willingly giving false or fraudulent information to get Lifeline Program benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program. (Required) My service provider may have to check whether I still qualify at any time. If I need to recertify (renew) my Lifeline benefit, I understand that I have to respond by the deadline or I will be removed from the Lifeline Program and my Lifeline benefit will stop. (Required) I understand that the free monthly internet is for only as long as the FCC program continues with the current funding (Required) I understand that I am participating in the ACP program with a one time, one per tax household benefit for a tablet. I acknowledge that I paid a $20 obligatory copay for the tablet, and I accept that this is the receipt for payment. I agree that Maxsip Telecom can contact me at any time to follow up on my subscription and future service offerings. Maxsip Telecom may put applications or advertising on my device. I understand and agree to the terms and conditions of the ACP program. If I am enrolled with another carrier, I authorize Maxsip Telecom to transfer my service to Maxsip Telecom as my ACP provider. If it is mid month I authorize Maxsip Telecom to transfer my service on the first of the following month. Your Signature(Required) Type your full legal name above.(Required) I understand this is a digital signature, and is the same as if I signed my name with a pen. Select Delivery Address(Required)Ship to same addressShip to a different addressShipping Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Price: $20 + FREE Shipping Payment to be collected upon ACP approvalPrice: $50 + FREE Shipping Payment to be collected upon ACP approvalPrice: $70 + FREE Shipping Payment to be collected upon ACP approvalCredit Card Full Name(Required) Credit Card Number(Required) Epiration Date( MM/YY)(Required) Credit Card Billing Zip Code(Required)
