Form B APPLICATION FOR TIME WARNER CABLE SENIOR CITIZEN DISCOUNT by richman5

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									Form B - 2004

         APPLICATION FOR TIME WARNER CABLE
               SENIOR CITIZEN DISCOUNT
                Application For Individuals Who Rent Or Own Their Home
                  And Do Not Receive A Real Property Tax Exemption
                    (If You Do Receive an Exemption - Use Form A)

Please follow these instructions to qualify for the Senior Citizen Discount.
In order to qualify for this discount, the applicant’s household gross
annual income cannot exceed $32,399.

This application, if approved, will qualify the resident of the below address
for $3.00 off the standard monthly price for the “full basic level of service”
for one year. The discount will not apply to those receiving broadcast
basic only or any additional movie or sports service. At the end of 12
months, a new application form needs to be submitted to continue the
service at the discounted rate. Otherwise, at the end of 12 months, the
subscription will return to the normal standard monthly rate. Applicant must
be head of household.

Application must be filed by May 15 with the Senior Resources Department at 6
Winners Circle, Colonie, New York 12205. It is the responsibility of the applicant
to provide all necessary information to the Town.

1.Name_________________________________________________________________
        (must be head of household and cable account must be in senior’s name)
2.Social Security No.______________________________________________________
3.Street Address__________________________________________________________
4.City and Zip Code_______________________________________________________
5.Phone Number__________________________________________________________
6.Time Warner Cable Account No. (if currently receiving cable)____________________
7.Are you currently receiving a senior discount from Time Warner Cable? Yes___ No___
8.Do you own/rent your home? Own_____________________ Rent_________________

Please submit a photocopy of one of the following with the application as proof of
your age (check the item):
              _________ Driver’s License         _________ DMV Senior ID Card
              _________ Birth Certificate        _________ Other (specify)
              _________ Baptismal Certificate


                                       (OVER)
As proof of eligibility, please submit a photocopy of one of the following to verify
your household gross annual income does not exceed $32,399. For those applicants
whose gross annual income exceeds $32,399, you may deduct from your income all
medical and prescription drug expenses which are not reimbursed or paid by
insurance in order to meet the $32,399 income qualification.

__________    Federal or New York State Income Tax Return for the preceding year and
              Social Security Income Statement (If you choose to submit a copy of your
              return, but at the present time it has not been prepared, please submit a
              copy by May 1st).
__________    Medicaid
__________    Supplemental Security Income (SSI)
__________    Home Energy Assistance Program (HEAP)
__________    Title XX Homecare
__________    Food Stamps

Please read and sign the following statement:

I certify that the above information is correct. I hereby authorize the Town of Colonie to
release this income information to Time Warner Cable to verify my eligibility for the
Senior Citizen Discount.

Signature of
Applicant________________________________________Date__________

To Be Completed By Town of Colonie

Upon the information presented, this applicant would qualify for a Section 467 of the
Real Property Tax Law exemption and, therefore, has met the qualifications set by this
municipality and Time Warner Cable for a senior citizen discount.

Municipal Official Name:______________________________________Date_________
Title:___________________________________________________________________

REMEMBER: PLEASE BRING/MAIL COMPLETED FORM TO
THE TOWN OF COLONIE SENIOR RESOURCES DEPARTMENT,
6 WINNERS CIRCLE, COLONIE, NEW YORK 12205 BY MAY 15.
THIS DISCOUNT WILL BECOME EFFECTIVE AS OF JULY 1.

								
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