Lifeline Phone Credit – New York
Lifeline is a federal government assistance program that grants eligible individuals a credit each month on their residential phone bill. You may qualify for a credit toward your monthly Time Warner Cable Phone service if you or a dependent receive low income benefits under certain programs or if your total household income is below 135% of the federal poverty guidelines. You must have (or sign-up for) Time Warner Cable Phone service PRIOR to receiving this credit. TimeWarner Cable’s Lifeline Phone Credit is only available for Time Warner Cable Phone service; whether in bundles or as a stand-alone product.
To demonstrate that you qualify for the Lifeline Phone Credit, complete Sections 1, 2 and 3 of this application. Please PRINT using black ink. Your application must be submitted with the required Proof of Eligibility. Instructions for submitting the application can be found in Section 4.
1
APPLICANT INFORMATION
Please complete this section in its entirety. If you are a current Time Warner Cable customer, please include your account number. Applications cannot be
processed if they do not include the Date of Birth of the applicant and the applicant’s last four digits of their Social Security Number.
2
LIFELINE CREDIT QUALIFICATION WORKSHEET
To apply for the Lifeline Phone Credit, you or a dependent must participate in a qualifying program or meet income-based criteria. You must complete either Section
A or B and send Proof of Eligibility as described in that section of the application. Applications cannot be processed if they do not include Proof of Eligibility.
A
B
PARTICIPATING PROGRAM
If you would like to apply using a qualifying program (like Medicaid or
Food Stamps), complete Section A. You must also identify whether the
qualifying program is in your name or the name of household member. If the qualifying program is in the name of a household member, you must
also provide their Date of Birth and the last four digits of their Social Security
Number or the application cannot be processed.
We cannot process your application unless we also receive a copy of
the correct Proof of Eligibility. Please reference the information below to
determine what proof can be accepted for each Qualifying Program. Also, if you are sending a copy of a Benefit ID Card, please make sure to
enter the appropriate ID number in the space provided on the application.
• M edicaid
•Benefit ID Card – The card should include program name, beneficiary name, state of residence, issue/effective date, and name of state agency that provided card in order to be eligible.
• Food Stamps/SNAP (Supplemental Nutrition Assistance Program)
•Award Letter which should include program name, date of award, beneficiary name and address
• B enefit ID Card – This card should include beneficiary name. If card does notinclude name, please submit Award Letter.
• S SI (Supplemental Security Income)
•Award Letter which should include program name, date of award,
beneficiary name and address
•Recent Social Security Administration benefit check stub with beneficiary name and date
• Federal Public Housing Assistance (Section 8)
•Award Letter which should include program name, date of award,
beneficiary name, and award amount.
•Public Housing Lease Agreement
•Recent Section 8 Voucher
• F amily Assistance/Safety Net Assistance/TANF
(Temporary Assistance for Needy Families)
•Award Letter which should include program name, date of award, beneficiary name, and award amount.
•Recent Utility Bill showing Energy Assistance Credit
• TANF (Temporary Assistance for Needy Families)
•Award Letter which should include program name, date of award, beneficiary name and address
• N SLP (National School Lunch Program) – Free Lunch Program Only
•Award Letter which should include program name, date of award, beneficiary name and address
• Veteran’s Disability Pension or Veteran’s Surviving Spouse Pension
• Award Letter or statement which should include date, beneficiary name and address
3
LEGAL REQUIREMENTS
In order to process your Lifeline Phone Credit application, please
acknowledge your agreement by initialing every statement and signing
the application. Please note, this application cannot be accepted unless
you initial each section and sign and date the application.
INCOME ELIGIBILITY
If you would like to apply based on income eligibility, use the chart below to determine if you qualify and complete Section B of the application. Using the total number of members in your household, determine if your total annual income level is at or below the level shown. Check the box on the application corresponding to your household and income level. (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).
OR
Household
Size
Maximum
Yearly
Income
Household
Size
Maximum
Yearly
Income
1
$16,038
6
$43,983
2
$21,627
7
$49,586
3
$27,216
8
$55,202
4
$32,805
More
than 8
5
$38,394
$55,202,
plus $5,616 for each
additional member
To apply, you must provide THE MOST CURRENT Proof of Eligibility
demonstrating your total gross annual income level. Note: If you
provide documentation that does not cover a full year (such as current
paycheck stubs), you must submit three (3) consecutive months’ worth of the same type of document from the previous twelve months.
• S
tate or Federal Tax Return (All pages)
• Income Statements from
Employer or Paycheck Stubs
• Retirement/Pension Benefit
Statements
• S
ocial Security Benefits
Statements
4
• W
2 Form
• V
eterans Administration Benefits
Statement
• U
nemployment OR Workers
Compensation Benefits
Statements
• O
ther
SUBMIT APPLICATION
In order for your application to be reviewed, you must send us Pages 2 and
3, plus a copy of the Proof of Eligibility as described above. Instructions for
submitting your application can be found in Section 4. You may mail or fax it.
Please allow up to ten (10) business days for application processing. For questions on the application
please call 1-800-892-2253. For ordering additional services with Time Warner Cable, please call 1-855-364-7799.
NY-APP-04/05/16-001
1
Lifeline Phone Credit – New York
TIME WARNER CABLE ACCOUNT HOLDER INFORMATION
1
Please PRINT clearly in black ink.
Time Warner Cable Account Number
TWC Phone Number
Last Name
First Name
Middle Initial
Residential Street Address (No PO Box)
Apt./Floor
City
State
Alternate Telephone Number
Email Address
Date of Birth (MM/DD/YYYY)
CHECK ONE BOX
/
Zip Code
Last Four Digits of Social Security Number
/
( One box must be checked or application cannot be processed):
I am currently receiving a Lifeline credit from another phone service provider and wish to transfer the Lifeline credit to Time Warner Cable.
I am applying for a Lifeline credit and do not currently have a Lifeline credit with another phone service provider.
LIFELINE CREDIT QUALIFICATION WORKSHEET
2
Indicate the household member eligible for the Lifeline Program. If ‘Other’, complete the additional required information.
S elf
O
ther: Enter full name of qualified individual
Their Date of Birth (MM/DD/YYYY)
A
/
/
Relationship to self
Their Last Four Digits of Social Security #
B
PARTICIPATING PROGRAM
Use the list below to determine if you are eligible based on income level.
Using the total number of members in your household, determine if your
total annual income level is at or below the level shown. Check the box
c orresponding to your household and income level. (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).
Check the box
of ONE program you participate in. Then, check
one of the boxes below the program you have chosen, to show which
acceptable proof of eligibility is being submitted with this application.
M edicaid
Benefit Card: Enter Benefit Card ID#
Food Stamps/SNAP (Supplemental Nutrition Assistance Program)
Award Letter
Benefit Card: Enter Benefit Card ID#
INCOME ELIGIBILITY
Household
Size
Maximum
Yearly
Income
Household
Size
Maximum
Yearly
Income
S SI (Supplemental Security Income)
Award Letter
1
$16,038
6
$43,983
Recent Social Security Administration benefit check stub
2
$21,627
7
$49,586
3
$27,216
8
$55,202
4
$32,805
More
than 8
Federal Public Housing Assistance (Section 8)
Award Letter
Public Housing Lease Agreement
Recent Section 8 Voucher
HEAP/LIHEAP (Low Income Home Energy Assistance Program)
Award Letter
Recent Utility Bill showing Energy Assistance Credit
F amily Assistance/Safety Net Assistance/TANF
(Temporary Assistance for Needy Families)
Award Letter
N SLP (National School Lunch Program) – Free Lunch Program Only
Award Letter
Veteran’s Disability Pension or Veteran’s Surviving Spouse Pension
Award Letter or statement
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OR
5
$38,394
$55,202,
plus $5,616 for each
additional member
Choose THE MOST CURRENT Proof of Eligibility demonstrating your
total gross annual income level.
S
tate or Federal Tax Return (All pages)
I ncome Statements from
Employer or Paycheck Stubs
R
etirement/Pension Statement of Benefits
S
ocial Security Statement of Benefits
W
2 Form
V
eterans Administration
Benefits Statement
U
nemployment OR Workers
Compensation Benefits
Statements
O
ther
CONTINUE TO PAGE 3
2
Lifeline Phone Credit – New York
LEGAL REQUIREMENTS
3
PLEASE ACKNOWLEDGE YOUR AGREEMENT BY INITIALING EVERY LINE BELOW AND SIGNING THE APPLICATION. YOUR
APPLICATION CANNOT BE APPROVED WITHOUT INITIALING ALL STATEMENTS! Refer to Page 1 instructions for a full description of the required Proof of Eligibility.
I understand that completion of this application does not constitute immediate approval for the Lifeline Phone Credit. I also understand that the credit will appear on
the first full bill cycle AFTER application approval and I am obligated to pay all billed charges prior to that period.
I authorize Time Warner Cable to access any records required to verify my statements herein and to confirm my eligibility for the Lifeline Phone Credit. I also authorize
Time Warner Cable to release any records required for the administration of the Lifeline Phone Credit program, including to the Universal Service Administrative Company
or state utility commission.
I am head of household and no one at my residence receives landline or wireless Lifeline service from another provider. An example of another landline provider that may
provide Lifeline service would be AT&T, CenturyLink or Verizon, and an example of another wireless provider that may provide Lifeline service would be Alltel Wireless,
T-Mobile, Assurance Wireless, or Safelink.
I understand that, by law, the Lifeline Phone Credit is only available for ONE RESIDENTIAL PHONE LINE 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.
• Violation of the one per household limitation constitutes a violation of the rules and will result in de-enrollment from the program.
I agree to notify Time Warner Cable immediately if I no longer meet the criteria for receiving the Lifeline Phone Credit (i.e. no longer meet the income-based or program-based
criteria, receive more than one Lifeline benefit, or another member of my household is also receiving a Lifeline benefit.)
I understand that if I move and either continue or re-establish service with Time Warner Cable, I will be required to re-apply for the Lifeline Phone Credit.
I understand that the Lifeline Phone Credit is a non-transferable benefit and may not be transferred to any other person.
I understand that I will be required to verify my continued eligibility for the Lifeline Phone Credit at any time and at least annually and that failure to do so will result
in de-enrollment and termination of the Lifeline Phone Credit benefits.
I understand that Lifeline Phone Credit is a federal benefit and willfully making false statements or providing false or fraudulent documents to obtain the benefit is
punishable by law and can result in fines, imprisonment, de-enrollment or being barred from the program.
SIGNATURE
By signing below, I certify under penalty of perjury that all the information contained in this
application is true and correct and that I meet the income-based or program-based eligibility
criteria for the Lifeline Phone Credit.
ave you provided your Date of Birth H
and your last 4 Digits of SSN?
Applicant Signature
Print Name
4
Date
/
ave you attached a copy of proof of
H
eligibility? DO NOT SEND ORIGINALS
/
ave you completed all sections above
H
and signed the application?
SUBMIT APPLICATION
Mail:
Time Warner Cable
OR
Attention: Voice Provisioning Department
789 Indian Church Rd, West Seneca, NY 14224
Fax:
1-855-284-0879
Your application cannot be processed
without these items.
Time Warner Cable Office Use Only – All sections must be completed
Submit Method:
Fax
Mail
Electronic
Reviewer must verify each section by initialing below:
Application complete and signed
Current and accurate proof submitted
Application Type:
New Enrollment
Proof retained and securely filed
Active account
Transfer of Enrollment from another carrier
Phone existing or order pending on account
Account noted with approval/denial + Reason Code
Identify the Supporting Documentation Presented:
A: PARTICIPATING PROGRAM
B: INCOME ELIGIBILITY
Medicaid
Benefit Card. Enter ID#:
Food Stamps/SNAP
Award Letter
Benefit Card. Enter ID#:
SSI
Award Letter
Social Security Admin check stub
Federal Public Housing Assistance
Award Letter
Public Housing Lease Agreement
Section 8 Voucher
HEAP/LIHEAP
Award Letter
Utility Bill showing Energy Assistance Credit
TANF
Award Letter
NSLP
Award Letter
Statement
Veteran’s Disability Pension or Veteran’s Surviving Spouse Pension Award Letter
Name on Proof
Description of Proof
APPLICATION REVIEWED BY: Employee Name (print):
Date Approved/Denied (MM/DD/YYYY):
/
/
Date Printed on Proof (MM/DD/YYYY)
/
/
EID:
I hereby attest that the supporting documentation was verified (signature required):
QUALITY CONTROL (VERIFY ALL FIELDS ON FORM FILLED OUT). COMPLETED BY:
Employee Name (print):
APPLICATION STATUS: Approved
Canceled per customer request
Denied:
App Incomplete (L1)
Proof Not Valid (L2)
Denied-NLAD (L3)
NY-APP-04/05/16-001
tate or Federal Tax Return
S
Income Statements from Employer or Paycheck Stubs
Retirement/Pension Benefit Statements
Social Security Benefits Statements
W2 Form
Veterans Administration Benefits Statement
Unemployment OR Workers Compensation Benefits Statements
Other (Divorce Decree or Child Support Documents)
EID:
Date:
/
/
Date:
/
/
Denied-TWC (L4) Describe
3