Claim Free Phone or Tablet

Which device do you prefer? *

Smart Phone

Tablet

Have you recieved a free smart phone or tablet through the Affordable Connectivity Program within the last calendar year? *

Yes

What is your projected yearly household income for 2024? *

No Income

I make below $22,590 per year

I make between $22,591-$50,000 per year

I make Over $50,000 per year

Important: Your name must appear as it is spelled on your official government documents, such as Social Security or benefits cards. Do not use nicknames. For example, use Patricia or Patrick rather than Pat.

First Name *

Middle Name

Last Name *

Email *

What is your phone number (if you have one)?

Please enter the best number to reach you.

Last 4 digits of your SSN *

If you do not have a SSN, what is your Tribal Identification Number?

Upload a Picture of Your Tribal Id (if applicable)

Where should we mail the phone or tablet?

Street Address *

Apartment or Unit Number

City *

State *

Postal code *

Date of Birth

Month *

Day *

Year *

Who is the Benefit Eligible Applicant? *

I am the Eligible Applicant

My Child or Dependent is the Eligible Applicant

You have indicated that you wish to qualify through a child or dependent in your household.

If this is correct press YES.

If you are applying for yourself, press NO

Select Here *

Yes

Child’s or Dependent’s First Name

Child’s or Dependent’s Last Name

Last 4 digits of Child’s or Dependent’s SSN

If they do not have a SSN, what is their Tribal Identification Number?

Dependent DOB

Which of the following BEST describes you

I have Medicaid

I have Medicaid AND Medicare

I have Medicare ONLY

I don't have Medicare OR Medicaid

What interests you most in a Medicare plan? *

Higher Dental

More Money in Food Cards

Better access to certain doctors or prescription drugs

I am happy with my current plan

Consent for E-Signature

By checking this box, you affirm "Yes" and agree to the Maxsip Tel LLC E-Signature Consent and affiliate terms and privacy policies. You must agree to the Terracom Inc., doing business as Maxsip Tel, E-Signature Consent policy to use electronic signatures for submitting your application online. Confirmation of Your Consent By providing your consent, you: Confirm you have reviewed and agree to the policy. Agree to electronically receive all communications, use electronic signatures, and acknowledge that you have the necessary hardware and software (including a PDF reader), along with email and SMS access, to receive communications electronically. Represent that you are authorized to provide this consent on your behalf. Authorization and Communication Your electronic signature authorizes approved individuals or companies to submit information to Maxsip on your behalf, including completing e-signature fields. This does not guarantee services but grants authorized entities the ability to complete the application for you. Should issues arise during the application process, you consent to be contacted via email, SMS, or phone call for clarification or to inform you of your application status and potential eligibility for additional services. Opting In and Your Rights By consenting and opting in, you acknowledge that: Even if you are currently on a do-not-call registry, you have opted into our communications. You are conducting a transaction with our authorized individuals or companies. You can stop SMS messages by replying STOP and opt out of emails via an unsubscribe link. During any telephone communication, you may request to be added to our opt-out/do-not-call list. Agreement By clicking "Yes, I agree" to the Maxsip Tel LLC E-Signature Consent, you are legally binding your agreement to these terms and conditions.

ACP Disclosures and Consent

By checking this box, I have read and understand the ACP Disclosures and Consent hereafter: 1. The ACP is a government program that reduces the customer’s broadband internet access service bill. The household may obtain ACP-supported broadband service from any participating provider of its choosing. 2. The household may apply the ACP benefit to any broadband service offering of the participating provider at the same terms available to households that are not eligible for ACP-supported service. 3. MaxSip Tel may disconnect the household’s ACP-supported service after 90 consecutive days of non-payment. 4. The household will be subject to MaxSip Tel’s undiscounted rates and general terms and conditions if the program ends; if the consumer transfers their benefit to another provider but continues to receive service from MaxSip Tel; or upon de-enrollment from the Affordable Connectivity Program. 5. The household may file a complaint against MaxSip Tel via the Commission’s Consumer Complaint Center or by calling (877)384-2575. 6. Eligibility for the ACP will be determined by the National Verifier, administered by the Universal Service Administrative Company (USAC). 7. ACP discounts can be applied to any available MaxSip Tel service plan. Available upload/download speeds will be determined by your particular service plan, and will be dependent on other factors, including network availability, as described in our standard Terms and Conditions , including the Acceptable Use Policy. 8. I understand that if I receive a connected device from MaxSip Tel as part of the ACP, I will pay a co-pay amount, as defined by the regulations of the ACP, in an amount over $10 and not exceeding $50. 9. I understand that ACP service benefits are limited to one per taxed household. 10. I give my express consent for MaxSip Tel and its contracted partners to install and activate software and other web applications on any tablet or other device that I have obtained from MaxSip Tel. 11. I understand that there are limitations with calling 911 when using Wi-Fi Calling services in comparison to calling 911 over your wireless service.

LIFELINE DISCLOSURES AND CONSENTS

By checking this box I have read and understand the lifeline disclosures and consents hereafter: 1. 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 Lifeline Program benefit. I understand that if this information is not provided to the Lifeline Program Administrator, I will not be able to get Lifeline 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 Lifeline Program Administrator. The information shared by the state or Tribal government will be used only to help find out if I can get a Lifeline Program benefit. 2. The Lifeline discount is limited to a single line of service. You may not apply for multiple Lifeline discounts and must choose to apply your Lifeline discount to either a landline or wireless number, but not both. Please note that other service providers may use terms other than “Lifeline” to describe the Lifeline program. By signing this application, you are certifying, under penalty of perjury, that you will comply with this requirement. Lifeline is only available to a subscriber whose residential address is located within Maxsip Lifeline service area. Lifeline may not be applied retroactively. 3. If USAC determines that I am receiving more than one Lifeline discount then all Lifeline providers involved may be notified so that I may select one Lifeline provider and be de-enrolled from the other. I understand that if I fail to provide consent, I will be denied Lifeline. 4. Lifeline discounts can be applied to any available MaxSip Tel service plan. Available upload/download speeds will be determined by your particular service plan, and will be dependent on other factors, including network availability, as described in our standard Terms and Conditions , including the Acceptable Use Policy. 5. You must pay all sales, excise and other taxes and governmental surcharges and fees that we are required by law to bill customers. These taxes, surcharges and fees may change from time to time without notice. However, Lifeline subscribers will not be assessed a Federal Universal Service Fund or Regulatory charge. 6. Qualifying customers will save $9.25 per month off of the monthly access charge. Qualified residents of federally recognized Tribal lands may receive up to $25 in additional Lifeline discounts per month. You will not be charged a service deposit to initiate Lifeline. However, you may be required to bring your account current if you incur charges materially in excess of your monthly access. Failure to bring your account current may result in a suspension or termination of your service.

CONSENT TO ENROLL IN MAXSIP TEL’S ACP AND LIFELINE PROGRAMS

You must check each block to acknowledge consent or your application will be rejected *

I acknowledge that I have received the above disclosures related to my request to enroll in Maxsip Tel’s Affordable Connectivity Program (ACP). I certify that I or a member of my household qualifies for ACP services and I want to enroll with MaxSip Tel LLC as my ACP provider. By clicking here I agree to be bound by MaxSip Tel’s Terms and Conditions and Privacy Policy.

I am providing written, signed consent and agree that the PII I provide may be collected, used, shared, and transmitted to a third-party for the purpose of verifying or correcting identification information and eligibility qualifications for Lifeline.

If I already am receiving Lifeline benefits from another service provider, I hereby prove written, signed consent and authorize the transfer of my Lifeline benefits to Maxsip Tel or its affiliate Terracom Inc. d/b/a Maxsip Tel.

MaxSip Tel offers all customers an optional, customized, software application that provides users with access to special promotions, unique offers and provides assistance with customer support and account services. By initialing here, I am providing written, signed consent that I would like to download and receive MaxSip Tel's software application on any connected device I receive from Maxsip.

I authorize MaxSip Tel and its service providers and/or affiliates to contact me, using the information I have provided herein via email, text (SMS), and telephone call using automated dialing technology for marketing or advertising purposes. *Consent is not a condition for purchase. Message and data rates may apply. To opt-out at any time; reply "STOP" to any text message received; follow the provided OPT-OUT INSTRUCTIONS, in any communications or contact our customer service at (866) 629-7471 or [email protected] and request to be removed from future communications. See our Privacy Policy. and Terms and Conditions .

I am providing written, signed consent and agree that the personally identifiable information (PII) I provide may be collected, used, shared and retained for the purpose of determining eligibility for the Lifeline and I understand my information may be transmitted to the ACP Administrator.

Click Here I consent to all of the above and provide permission to enroll me in MaxSip Tel’s ACP and Lifeline Plan

MAXSIP TEL ACP FUTURE ENROLLMENT CONSENT

You must check each block to acknowledge consent or your application will be rejected *

I acknowledge and understand that effective February 7, 2024, the FCC has issued an enrollment freeze, due to lack of funding, which currently prevents me from applying to and receiving benefits under the ACP.

I am providing written, signed consent and agree that the personally identifiable information (PII) I provide may be collected, used, shared, stored and otherwise retained by Maxsip Tel and/or by any of its affiliates for the purpose of determining my past, present or future eligibility for the ACP. I understand my PII may be transmitted to the ACP Administrator.

I would like to enroll in the ACP with Maxsip Tel and/or one of its Affiliates as my service provider if and when the ACP is re-funded.

I am providing written, signed consent and hereby request that Maxsip Tel stores my PII using commercially reasonable methods and utilizes my personal information to promptly enroll me in the ACP if and when funding is reissued for the ACP. I authorize Maxsip Tel to interact with the National Verifier and ACP Administrator on my behalf for the purposes of enrolling me in the ACP if and when the Program is refunded. I hereby consent to enrolling with Maxsip Tel and/or one if its Affiliates as my service provider at the time of ACP refunding.

I acknowledge that I have received the above disclosures related to my request to enroll in Maxsip Tel’s Affordable Connectivity Program (ACP). I certify that I or a member of my household qualifies for ACP services and I want to enroll with Maxsip Tel as my ACP provider. By clicking here I agree to be bound by MaxSip Tel’s Terms and Conditions and Privacy Policy.

LIFELINE BENEFIT TRANSFER

Do you consent to enrollment or transfer into Maxsip Tel's Lifeline Program, and do you understand that you are not allowed to multiple Lifeline program benefits with the same or different providers? Please answer yes, or no. *

Yes

E-SIGNATURE

My E-Signature below gives consent to an affiliate/individual/company authorized to submit this application on your behalf to Maxsip to apply and enroll for ACP and/or lifeline services: *

Clear

Today's Date *

CONFIRMATION OF CONSENT

You must check all boxes or your application may be rejected *

By providing your Consent, you confirm you have reviewed the policy and agree (1) to electronically receive all Communications; (2) to use electronic signatures; and (3) that you have hardware, software (including PDF reader), email and SMS access to receive Communications electronically. You represent that you are authorized and are providing this Consent on behalf of yourself. By clicking Yes, I agree to the Maxsip Tel LLC E-Signature Consent

Click Here to Accept and E-Sign All Of the Above ACP Disclosure and Consent

Click Here to Accept and E-Sign All Of the Above LIFELINE Disclosure and Consent

Click Here I consent to all of the above and provide permission to enroll me in MaxSip Tel’s ACP and Lifeline Plan

Click Here to Accept and E-Sign Maxsip Tel ACP Future Enrollment Consent

Please Fill Out the Survey Below

How do you qualify for Lifeline Service?