Rockaway Home Care - Free Internet Program

Rockaway Home Care Free Tablet Signup

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Your household cannot get the ACP benefit from more than one company. You are only allowed to get one ACP benefit per household, not per person.

A household is a group of people who live together and share income and expenses (even if they are not related to each other). Complete the ACP household worksheet to determine if more than one qualifying household is located at your address. If more than one person in your household participates in the ACP, you are breaking the FCC's rules and will lose your benefit.

The ACP benefit is non-transferable. You cannot give your benefit to another person, even if they qualify for the ACP.

You must give accurate and true information on this form and on all ACP related forms or questionnaires. If you give false or fraudulent information, you will lose your benefit (i.e., de-enrollment or being barred from the program) and the United States government can take legal action against you. This may include (but is not limited to) fines or imprisonment.

CAPTCHA

Do you live with another adult?(Required)

Yes

Adults are people who are 18 years old or older, or who are emancipated minors. This can include a spouse, domestic partner, parent, adult son or daughter, adult in your family, adult roommate, etc

Do they get the ACP benefit?(Required)

Yes

Do you share money (income and expenses) with them?(Required)

Yes

This can be the cost of bills, food, etc., and income. If you are married, you should check yes for this question.

You do not qualify for the ACP because someone in your household already gets the benefit. You are only allowed to get one ACP benefit per household, not per person.

Please check the box that best describes the building where you live

Apartment building

Single family home

Residential facility (such as a nursing home or assisted living facility)

Transitional housing or shelter

Other

I live at an address with more than one household.(Required)

I understand that the one-per-household limit is a Federal Communications Commission (FCC) rule and I will lose my Affordable Connectivity Program benefit if I break this rule.(Required)

Legal Name(Required)

First Middle Last

Phone(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Last 4 digits of your SSN(Required)

Email(Required)

Legal Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Do you want to ship to another address?(Required)

Yes

Shipping Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Check the programs that you or someone in your household have:(Required)

Supplemental Nutrition Assistance Program (SNAP, also called Food Stamps)

Supplemental Security Income (SSI)

Medicaid

Federal Public Housing Assistance (FPHA)

Veterans Pension or Survivors Benefit Programs

Federal Pell Grant for the current award year

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Tribal Specific Programs

I do not participate in any of the above programs. I would like to qualify through my income

You only need one of these programs to qualify for the free monthly internet.

Tribal Specific Programs(Required)

Bureau of Indian Affairs (BIA) General Assistance

Tribal Temporary Assistance for Needy Families (Tribal TANF)

Food Distribution Program on Indian Reservations (FDPIR)

Tribal Head Start (only households that meet the income qualifying standard)

I agree, under penalty of perjury, to the following statements:(Required)

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).

I agree that if I move I will give my internet company my new address within 30 days

I understand that I have to tell my internet company 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.

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 companies.

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.

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 company’s undiscounted general rates, terms, and conditions if my household continues to subscribe to the service

All the answers and agreements that I provided on this form are true and correct to the best of my knowledge.

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.

The certification applies to all consumers and is required to process your application. I was truthful about whether or not I am a resident of Tribal lands, as defined in the "Your Information" section of this form.

I agree to allow Rockaway Home care to share my information with Maxsip Telecom for purposes of this ACP (free internet program).

I agree to allow Maxsip to put a MDM onto my device to help me with my user experience and apps.

Verbal Consent(Required)

By checking this box I am agreeing to the terms and conditions above or I have received a verbal consent and agreement from the participant, if I am filling this form out for them.(Required)

I understand this is a digital signature, and is the same as if I signed my name with a pen.(Required)

We need the name of the person filling out the form in case we need to contact you with any questions.

What is your Name?(Required)

First Last

What is your Phone(Required)

What is your Email(Required)

Enter Email Confirm Email

What is your relationship to the Applicant?(Required)

Self

NCM

Agency Representative