IMPORTANT, READ BEFORE SIGNING Limited Liability Agreement The applicant hereby agrees that the CPUC and/or the State of California, and/or the California Communications Access Foundation (CCAF) make(s) no warranties, either express or implied, with regard to the possession, use, condition, and/or operation of the telecommunications equipment provided to applicant as part of this program (the Equipment). The applicant hereby agrees to indemnify, defend, and hold harmless the CPUC, the State of California, and/or the CCAF from any and all third party claims, costs (including without limitation reasonable attorneys’ fees), and losses which in any way arise out of or in connection with the possession, use, condition, and/or operation of the Equipment. The applicant hereby agrees that the CPUC, the State of California, and/or the CCAF shall have no liability to the applicant or any other person with respect to any liability, loss, or damage caused or alleged to be caused, directly or indirectly, by or through the possession, use, and/or operation of the Equipment. I verify that I live in a household that subscribes to telephone service in California.

NOTE:Please choose your equipment carefully because we want to provide you the most appropriate phone. CTAP will repair or exchange equipment if 1) the equipment loaned to the consumer stops working or malfunctions or 2) the consumer’s disability certification changes. Please return your equipment with all original parts in the manufacturer’s packaging.

PRIVACY NOTICE: The CPUC DDTP, under the authority of Public Utilities Code § 2881, uses this form to collect personal information solely for the purposes of identification and document processing. Unless otherwise noted, all requested information is mandatory, and incomplete information may result in incorrect processing. The information submitted will be held in confidence to the extent allowed by law and is available for your review, upon request. The DDTP complies with the Information Practices Act of 1977, and its Privacy Policy and contact information are online at https://ddtp.cpuc.ca.gov/privacy.aspx. https://ddtp.cpuc.ca.gov/privacy.aspx

2. Have this section completed by an authorized certifying agent.

3. Choose one way to return this form.

If you mail, fax, or email your completed form, you will receive a letter or phone call about how to select the best phone for your needs and it will be shipped to you. If you bring your form to a Service Center, you will be able to try out the phone and take it home with you.

Contact Center hours: Monday - Friday (8:00 AM - 6:00 PM), except holidays. Please check the website or call the Contact Center to confirm hours.