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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