LIFELINE TELEPHONE APPLICATION Questions?Call 1-844-267-2333
ThissignedapplicationisrequiredinordertoenrollyouintheLifelineprogramasapprovedbytheFederalCommunicationsCommission(FCC).TheformisonlyforthepurposeofcertifyingyoureligibilityfortheLifelineprogramandwillnotbeusedforanyotherpurpose.Pleaseuseblackorblueinkonly.Mailthecompletedformandcopiesofproofofeligibilityto:CoxCommunications,Attention:LifelineServices,6301WaterfordBlvd,Suite200,OklahomaCity,OK73118ORyoumayfaxcompletedformandcopiesofproofofeligibilityto:1-877-873-9077.
APPLICANTINFORMATION
FirstName
HomeAddress(CannotbeaP.O.Box)
MiddleInitial LastName
City State Zip
Theaboveaddress is: PERMANENT TEMPORARY HomePhoneNumber*
*Byprovidingmysignature,IconsenttocontactfromCoxCommunicationsoritssubsidiaries,atthetelephonenumberIprovidedregardingproductsorservicesvialive,automatedorprerecordedtelephonecall.IunderstandIamnotrequiredtoenterintothisagreementasaconditionofpurchasingproperty,goods,orservices.
Applicant’sSignature:
BillingAddress(ifdifferent)
City State Zip
IMPORTANTDISCLOSURES• Lifeline is a federal benefit. Willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the program. • Only one Lifeline service is available per household. • A household is defined, for purposes of the Lifeline program, as any individual or group of individuals who live together at the same address and share income and expenses. • AhouseholdisnotpermittedtoreceiveLifelinebenefitsfrommultipleproviders.• Violation of the one-per-household limitation constitutes a violation of Federal Communications Commission rules and will result in the subscriber’s de-enrollment from the program. • Lifelineisanon-transferablebenefitandthesubscribermaynottransferhisorherbenefittoanyotherperson.
STEP1:AreyouacurrentCoxTelephonecustomer? Yes No
STEP 2: IauthorizeCoxtotransferanypre-existingLifeline benefitwithanothercarriertomyCoxaccount,subjecttoalltermsandconditionsdescribedinthisapplication.Iacknowledgethatanypre-existingLifelinediscountwithanothercarrierwillceasewhenthistransferbecomeseffective.
Yes No
STEP 3: IunderstandthatifIvoluntarilyelecttollrestriction,itwillblocklongdistance,collectandthirdpartycallingandCoxwillwaiveanyapplicabledeposit.IalsounderstandthatifIcanceltollrestriction,Coxwillrequirepaymentofthepreviouslywaiveddeposit.
Ivoluntarilyelecttollrestriction Idonotwishtohavetollrestriction
STEP 4: NATIONALLIFELINEACCOUNTABILITYDATABASEDISCLOSUREANDCONSENT.TheFCChasorderedthecreationofaNationalLifelineAccountabilityDatabase.CoxmustprovidethebelowinformationaboutourrelationshipwithyoutothedatabasetoensuretheproperadministrationoftheLifelineprogram:
• Your full name• Your date of birth • Your telephone number
• Your full residential address • The amount of the discount Cox provides • Whether your eligibility is program or income based
• The date Cox began providing you with Lifeline service• The future date when your Lifeline service with Cox ends • The last four digits of your Social Security number (or Tribal ID)
Bymyinitialsandbysigningthisapplication,IconfirmIhavereadandunderstandthedisclosuresprovidedaboveandherebyprovideconsenttoCoxtoprovidetheinformationdescribedabovetotheLifelineServiceAdministratorforinclusioninthedatabase. (FailuretoprovideconsentwillresultinbeingdeniedLifelineservice.) APPLICANT’SINITIALS
ELIGIBILITYREQUIREMENTS. Select whether you are applying for Lifeline eligibility based on (A) participation in a qualifying government program OR (B) total annual income before tax deductions (see next page).
(A) PROGRAMBASEDPARTICIPATION
IherebycertifythatIoramemberofmyhouseholdparticipatesinatleastoneoftheprogramslistedbelow.CheckALLthatapply:
Medicaid(note:thisisnotthesameasMedicare)
SupplementalNutritionAssistanceProgram(SNAP–FoodStamps)
SupplementalSecurityIncome(SSI)
FederalPublicHousingAssistance(FPHA)orSection8
VeteransPension&SurvivorsPensionbenefit
APPLICATIONCONTINUEDONBACK
www.cox.com/lifelineRev 01/24/2018
STEP 5:
Totalnumberofpersons intheabovehousehold:
Totalannualhouseholdgross income:$
(B) INCOMEBASEDELIGIBILITY2018FEDERALPOVERTYGUIDELINES*
Thischartreflectstheeligibilityguidelinesforcustomersat135%ofthefederalguidelines.
Mytotalhouseholdgross incomeisatorbelow135%of
theFederalPovertyGuidelines(Refertochartontheright.)
NewguidelinesarepublishedannuallybytheU.S.DepartmentofHealthandHumanServices(DHHS)
STEP6: PROOFOFELIGIBILITY.PhotocopyoneormoreofthefollowingacceptableproofsofyoureligibilityfromStep5andsubmitwiththisLifelineapplication.(CoxcannotestablishyourLifelinecredituntilwereceive documentation.)
(A) PROGRAMBASEDELIGIBILITYIhaveattachedcopiesofoneormoreofthedocumentslistedbelow:
Thecurrentorprioryear’sstatementofbenefitsfromtheprogrammarkedinstep5Anoticeletterofparticipationintheprogrammarkedinstep 5Aprogramparticipationdocumentfromtheprogrammarkedinstep5,forexample,aSNAPelectronicbenefittransfercardoraMedicaidparticipationcardOtherofficialdocumentprovingyourparticipationintheprogrammarkedinstep5.Describe:
BenefitQualifyingPerson(ProvideinformationbelowonlyifnameisdifferentfromApplicantorCoxAccountHolder)
FullNameofhouseholdmemberreceivingabove benefits: Or Self
Householdmemberreceivingbenefit:DateofBirth Last4digitsofSocialSecurityNumber(orTribalIDifSSNisnotavailable)
(B) INCOMEBASEDELIGIBILITY
Ihaveattachedcopiesofoneormoreofthedocumentslistedbelow:NOTE:Ifyouprovidedocumentationofyourincomethatdoesnotcoverafullyear,youmustsubmitthreeconsecutivemonths’worthofthesametypeofdocumentwithinthelasttwelvemonths.
Prioryear’sfederal,stateorTribalTaxreturn
Veteran’sAdministrationbenefitsstatement
DivorceDecree/childsupportdocument
Federal or TribalGeneral AssistanceNotice Letter
Unemployment/WorkersCompensation benefit statementorpaycheckstub
SocialSecuritybenefitsstatement
Retirement/Pensionbenefitstatement
Currentincomestatementfromemployer
Otherofficialdocumentcontainingincomeinformation
STEP7: SIGN&DATE.BYMYINITIALSANDBYSIGNINGBELOW,ICERTIFYTHAT:Initialeachitemlistedandsignbelow.
Underpenaltyofperjurythattheinformationcontainedinthisapplicationistrueandcorrecttothebestofmy knowledge.ImeettheprogramorincomebasedeligibilitycriteriaforreceivingLifelinebenefits.
ThetelephoneserviceforwhichIamrequestingLifelineisinmynameandthisLifelinetelephoneaccountwillrepresenttheonlyLifelinetelephoneserviceprovidedtomyhousehold,andIamawarethatIcanonlyreceivetheLifelinetelephonediscountononephoneline(wirelineorwireless).
(Onlyifapplicable)Iftheaddressaboveisatemporaryaddress,Imayberequiredtoverifymytemporaryaddressevery90days.IfImovetoanotheraddress,IwillprovidenoticeofthataddresstoCoxwithin30days.Iamnotlistedasadependentonanotherperson’sincometaxreturn(unlessovertheageof60).Theaddresslistedonthisapplicationismyprimaryresidence,notasecondhomeorbusiness.IacknowledgethatprovidingfalseorfraudulentdocumentationinordertoreceiveLifelinebenefitsispunishablebylaw.IacknowledgethatImayberequiredtore-certifymycontinuedeligibilityforLifelineassistanceatanytimeandthatfailuretodosowillresultinde-enrollment
andterminationofLifelineservice.IunderstandthatifIfailtore-certifymyeligibilityandIamde-enrolled,Iwillberequiredtopaythefulltariffedmonthlyrecurringchargesformytelephone
servicegoingforward.If,inthefuture,Inolongerparticipateinatleastoneofthefederallyqualifyingprogramsormytotalhouseholdincomeexceeds135%ofthe Federal
PovertyGuidelineslistedinstep5,Ibeginreceivingbenefitsfromanothercarrier,or ifconditionsabovechange,IwillpromptlynotifyCoxwithinthirty(30)daysthatIam nolongereligibleforLifelineassistance. In12months,Iwillneedtore-certifymyparticipationintheLifelineprogram.
Iaffirmunderpenaltyofperjury,thattheforegoingrepresentationsaretrue. (Coxwillnotprocessthisapplicationwithoutasignature,dateofbirthandlast4digitsofSocialSecurityNumber.)
Applicant’sSignature Date
DateofBirth Last4digitsofSocialSecurityNumber(orTribalIDifSSNisnotavailable)
www.cox.com/lifelineRev 01/24/2018
PersonsinHousehold Annual ncomeLimits*
1 $16,3892 $22,221
3 $28,053
4 $33,885
5 $39,717
6 $45,549
7 $51,381
8 $57,213Ov P eachadditionalperson
$5,832
* Prior year’s federal, state or Tribal Tax return
* Veteran’s Administration benefits statement
* Divorce Decree/child support document
* Federal or Tribal General Assistance Notice Letter
* Unemployment/Workers Compensation benefit statement or paycheck stub
* Social Security benefits statement
* Retirement/Pension benefit statement
* Current income statement from employer
* VA Pension Grant Letter
* VA Pension COLA Letter
* Survivor Benefit Summary Letter
* Other official document containing income information