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