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Which service would you like to apply for?
- 4G Tablet With Internet (Valued at $300) & Free Monthly Service
15GB Data Monthly for the Tablet
What is your full legal name? The name you use on official documents, like your Social Security Card or State ID. Not a nickname.
Name*
First Name Last Name
What is your date of birth?*
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*

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Your Phone Number*
Please leave out the 1 before the number.
Your Email*
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.
Enter Email Confirm Email
What is your home address?*
This is where we will ship your device

Street Address Address Line 2 City State ZIP Code
Currently this program is only for the following states (New York, New Jersey, Alabama, Alaska, Colorado, District of Columbia, Idaho, Iowa, Maryland, North Dakota, Ohio, Oklahoma, Texas, Arkansas, Connecticut, Delaware, Florida, Georgia, Hawaii, Indiana, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, & Wyoming). If you want to apply using an address from another state, continue filling out the form and when we have more states, we can process your order.

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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.
Who Qualifies?*
- I qualify for the program on my own
- I ONLY qualify through my child or dependent
Qualifications
- You are eligible for the ACP if your income is 200% or less than the Federal Poverty Guidelines. The guideline is based on your household size and state.
- You are eligible for the ACP if you (or someone in your household) participate in one of these programs:
- If you live on qualifying Tribal lands, you are eligible for the ACP if your household income is at or below 200% of the Federal Poverty Guidelines, or if you (or someone in your household) participate in:
- If you currently receive a Lifeline benefit, you automatically qualify for the ACP, and you can receive both benefits at the same time. You can apply your ACP benefit and your Lifeline benefit to the same or separate services.
- Any member of your household can make your household eligible if they participate in one of the programs above. For example, if your child or dependent participates in the Free and Reduced-Price School Lunch Program or is enrolled in a USDA Community Eligibility Provision school, your household qualifies for the ACP benefit.

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To qualify for the Emergency Broadband Benefit, we need to know which government assistance program your child or dependent is in.
To qualify for the Free Internet Benefit, we need to know which government assistance program you are in.
Check all that apply*
- Medicaid
Which Tribal specific programs do you have?*
- 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)
Enter your (or your dependent's) University or College*
Enter name of school*
How many people live in your household?*
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
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)
To prove participation, submit one of the following acceptable documents:
- Letter or email from School or School district that confirms a member of the household receives free or reduced school lunch/breakfast for the 2019-2020 and/or 2020-2021 school years (if you are providing an email that your school sent out, please note that it must include your legal name, and date of the email. The easiest way to do this is to select print on the email and download as a PDF in google chrome.)
- Written proof that the child is enrolled in a School or School district that participates in the Community Eligibility Provision for the 2019-2020 and/or 2020-2021 school years
The document must include:
- Your name, or your dependent's name
- Name of School or School District
- Name of qualifying program (lunch and/or breakfast)
- School year of either 2019-2020 or 2020-2021
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

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I certify, under penalty of perjury, that:*
I certify, under penalty of perjury, that:*
1. I (or my dependent or other person in my household) currently get benefits from the government program(s) listed on this form or my annual household income is 200% or less than the Federal Poverty Guidelines (the amount listed in the Federal Poverty Guidelines table on this form).
2. I agree that if I move I will give my service provider my new address within 30 days. I understand that I have to tell my service provider within 30 days if I do not qualify for the ACP anymore, including:
  
  1. I, or the person in my household that qualifies, do not qualify through a government program or income anymore.
  
  2. Either I or someone in my household gets more than one ACP benefit.
3. I know that my household can only get one ACP benefit and, to the best of my knowledge, my household is not getting more than one ACP benefit. I understand that I can only receive one connected device (desktop, laptop, or tablet) through the ACP, even if I switch ACP providers.
4. I agree that all of the information I provide on this form may be collected, used, shared, and retained for the purposes of applying for and/or receiving the ACP benefit. I understand that if this information is not provided to the Program Administrator, I will not be able to get ACP benefits. If the laws of my state or Tribal government require it, I agree that the state or Tribal government may share information about my benefits for a qualifying program with the ACP Administrator. The information shared by the state or Tribal government will be used only to help find out if I can get an ACP benefit.
5. For my household, I aﬀirm and understand that the ACP is a federal government subsidy that reduces my broadband internet access service bill and at the conclusion of the program, my household will be subject to the provider’s undiscounted general rates, terms, and conditions if my household continues to subscribe to the service.
6. All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.
7. I know that willingly giving false or fraudulent information to get ACP benefits is punishable by law and can result in fines, jail time, de-enrollment, or being barred from the program.
8. I was truthful about whether or not I am a resident of Tribal lands, as defined in the "Your Information" section of this form.
Consent - The Affordable Connectivity Program (ACP)*
The Affordable Connectivity Program (ACP) is limited to one device discount per household. Your household cannot get the ACP benefit from more than one service provider at a time and can only receive one connected device through the ACP.

I understand that I am participating in the ACP with a one time, one per tax household benefit for a tablet. I acknowledge that I paid an 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. 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*
The Affordable Connectivity Program (ACP) is limited to one device discount per household. Your household cannot get the ACP benefit from more than one service provider at a time and can only receive one connected device through the ACP.

I understand that I am participating in the ACP with a one time, one per tax household benefit for a tablet. I acknowledge that I paid an 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. 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*

Type your full legal name above.
I understand this is a digital signature, and is the same as if I signed my name with a pen.*
I understand this is a digital signature, and is the same as if I signed my name with a pen.*
Product Name
Price:
$15 Tablet + FREE Shipping
Co-pay Code
Total
$0.00
Payment to be collected upon ACP approval

Credit Card*

Cardholder Name

Card Details

Phone
This field is for validation purposes and should be left unchanged.

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Free Internet Signup

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