Lifeline Telephone Application (Page 2 of 2) in pdf

2017 FEDERAL POVERTY GUIDELINES*

(B)

INCOME BASED ELIGIBILITY

This chart reflects the eligibility guidelines for customers

at 1 35% of the federal g

uidelines.

Total number of persons in the above household:

Persons in Household

Annual

ncome Limits*

$16,281

Total annual household income: $

27,567

My total household i ncome i s at or below 1

35% of the

33,210

Federal Poverty G

uidelines (Refer to chart on the right.)

38,853

50,139

55,782

P each

$5,643

additional person

New guidelines are published annually by the U.S. Department of Health and Human Services (DHHS)

STEP 6:

PROOF OF ELIGIBILITY. Photocopy one or more of the following acceptable proofs of your eligibility from Step 5 and submit with this Lifeline

application. (Cox cannot establish your Lifeline credit until we receive

documentation.)

(A)

PROGRAM BASED ELIGIBILITY

I h ave attached c opies o f one o r m ore o f t

he documents listed below:

The current or prior year’s statement of benefits from the program marked in step 5

A notice letter of participation in the program marked in step

A program participation document from the program marked in step 5, for example, a SNAP electronic benefit transfer card or a

Medicaid participation card

Other official document proving your participation in the program marked in step 5. Describe:

Benefit Q ualifying P

erson (Provide information below only if name is different from Applicant or Cox Account Holder)

Full Name of household member receiving above benefits:

Self

Household member receiving benefit: Date of Birth

Last 4 digits of Social Security Number (or Tribal I D if SSN is not available)

(B)

INCOME BASED ELIGIBILITY

I have attached copies of one or more of the documents listed below: NOTE: If you provide documentation of your income that does not

cover a full year, you must submit three consecutive months’ worth of the same type of document within the last twelve months.

Prior year’s federal, state or Tribal Tax return

Social Security benefits statement

Prior year’s federal, state or Tribal Tax return

Retirement/Pension benefit statement

Veteran’s Administration benefits statement

Current income statement from employer

Veteran’s Administration benefits statement

Retirement/Pension benefit statement

Divorce Decree/child support document

VA Pension Grant Letter

Divorce Decree/child support

document

Current income statement from

employer

Federal or Tribal General Assistance Notice Letter

VA Pension COLA Letter

Federal or Tribal General Assistance Notice Letter

Other official document containing income information

Unemployment/Workers Compensation benefit statement or paycheck stub

Survivor Benefit Summary Letter

Unemployment/Workers Compensation benefit statement

Social Security benefits statement

Other official document containing income information

or paycheck stub

SIGN & DATE. BY MY INITIALS AND BY SIGNING BELOW, I CERTIFY THAT: Initial each item listed and sign below.

STEP 7:

Under penalty of perjury that the information contained in this application is true and correct to the best of my

knowledge.

I meet the program or income based eligibility criteria for receiving Lifeline benefits.

The telephone service for which I am requesting Lifeline is in my name and this Lifeline telephone account will represent the only Lifeline telephone service

provided to my household, and I am aware that I can only receive the Lifeline telephone discount on one phone line (wireline or wireless).

(Only if applicable) If the address above is a temporary address, I may be required t o verify my temporary address every 90

days.

If I move to another address, I will provide notice of that address to Cox within 30 days.

I am not listed as a dependent on another person’s income tax return (unless over the age of 60).

The address listed on this application is my primary residence, not a second home or business.

I acknowledge that providing false or fraudulent documentation in order to receive Lifeline benefits is punishable b

ylaw.

I acknowledge that I may be required to re-certify my continued eligibility for Lifeline assistance at any time and that failure to do so will result in de- enrollment

and termination of Lifeline service.

I understand that if I fail to re-certify my eligibility and I am de-enrolled, I will be required to pay the full tariffed monthly recurring charges for my telephone

service going forward.

If, in the future, I no longer participate in at least one of the federally qualifying programs or my total household income exceeds 135% of the Federal

Poverty Guidelines listed instep 5, I begin receiving benefits from another carrier, or if conditions above change, I will promptly notify Cox within thirty (30)

days that I am no longer eligible for Lifeline assistance.

In 12 months, I will need to re-certify my participation in the Lifeline program.

I affirm under penalty of perjury, that the foregoing representations are true. (Cox will not process this application without a signature, date of

birth and last 4 digits of Social Security Number.)

Date

Applicant’s Signature

Date of Birth

Last 4 digits of Social Security Number

(or Tribal ID if SSN is not available)

Rev

02/20/2017