Lifeline Telephone Application printable pdf download

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LIFELINE TELEPHONE APPLICATION

This signed application is required in order to enroll you in the Lifeline program as approved by the Federal Communications Commission (FCC). The form is only for the

purpose of certifying your eligibility for the Lifeline program and will not be used for any other purpose. Please use black or blue ink only.

Mail the completed form and copies of proof of eligibility t o: Cox Communications, Attention: L

ifeline Services, 6301 Waterford Blvd, Suite 200, Oklahoma City, OK 73118

OR you may fax completed form and copies of proof of eligibility to: 1-877-873-9077.

APPLICANT INFORMATION

First N

ame

Middle Initial

Last Name

Home Address (Cannot be a P.O. Box)

City

State

Zip

The above address is:

PERMANENT

TEMPORARY

Home Phone Number*

*By providing my signature, I consent to contact from Cox Communications or its subsidiaries, at the telephone number I provided regarding products or

services via live, automated or prerecorded telephone call. I understand I am not required to enter into this agreement as a condition of purchasing

property, goods, or s

ervices.

Applicant’s Signature:

Billing Address (if d ifferent)

City

State

Zip

IMPORTANT DISCLOSURES

•

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.

•

A household is not permitted to receive Lifeline benefits from multiple

providers.

•

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.

•

Lifeline is a non-transferable b enefit and the subscriber may not transfer h

is or her benefit to any other person.

STEP 1: Are you a current Cox Telephone customer?

Yes

STEP2:

I authorize Cox to transfer any p re-existing Lifeline benefit with another carrier t o my Cox account, s ubject to all terms and c onditions described

in this a pplication. I acknowledge t hat any pre-existing Lifeline d iscount with another carrier will cease w

hen this transfer becomes effective.

Yes

I understand that if I voluntarily elect toll r estriction, i t will block l ong distance, collect and t hird party calling and C ox will waive a ny

STEP3:

applicable deposit. I also understand that if I cancel toll restriction, Cox will require payment of the previously waived deposit.

I do not wish to have toll restriction

I voluntarily elect toll restriction

STEP4:

NATIONAL LIFELINE ACCOUNTABILITY DATABASE DISCLOSURE AND CONSENT. The F CC has ordered t he creation o f a National Lifeline

Accountability Database. Cox must provide the below i nformation about our relationship with you to the database to ensure the

proper administration of the Lifeline program:

•

The date Cox began providing you with Lifeline service

•

Your full name

•

Your full residential address

•

Your date of birth

•

The amount of the discount Cox provides

•

The future date when your Lifeline service with Cox ends

•

Whether your eligibility is program or income based

•

Your telephone number

•

The last four digits of your Social Security number (or Tribal ID)

By my initials and by signing this application, I confirm I have r ead and understand the disclosures provided above and hereby provide consent to

Cox to provide the information described above to the Lifeline Service Administrator for inclusion in the database. (Failure to provide consent

will result in being denied Lifeline service.)

APPLICANT’S INITIALS

STEP 5:

ELIGIBILITY R

EQUIREMENTS. Select w hether y ou a re applying f or L ifeline eligibility b ased o n ( A) p articipation i n a q ualifying g overnment p rogram

OR (B) t otal a nnual household income guidelines ( next p

age.)

(A)

PROGRAM BASED PARTICIPATION

I hereby certify that I or a member of my household p articipates in at least o ne of the programs listed below. Check ALL t

hat apply:

Federal Public Housing Assistance (FPHA) or Section 8

Medicaid (note: this is not the same as

Medicare)

Veterans Pension & Survivors Pension benefit

Supplemental N utrition A ssistance P rogram ( SNAP–Food S tamps)

Supplemental Security Income (SSI)

APPLICATION CONTINUED O

NBACK

Rev

02/20/2017

Lifeline Telephone Application

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