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Com.au Community Service C Tariff Application Form 1. Applicant details Name of organisation Address lot number Street number Street Suburb/town/city Account number Fax Postcode Telephone number Email 2. Horizon Power Residential enquiries 1800 267 926 Business enquiries 1800 737 036 Facsimile 1800 420 998 Email enquiries horizonpower-reply. Eligibility Criteria To support your application for the C2 Tariff please provide evidence of the following Organisation is a direct customer of Horizon Power copy of Horizon Power bill voluntary Endorsement by the Commissioner of Taxation that organisation is exempt from income tax under Subdivision 50-B of the income Tax Assessment Act 1997 copy of Endorsement as an Income Tax Exempt Charitable Entity Organisation provides a public service available to any member of the public without discrimination have majority funding from one of these organisations copy of audited financial accounts or Annual Report 3. Declaration I hereby declare the organisation named above meets all eligibility criteria as required by Horizon Power to apply for the Name Position Signature please print Date 10/11. Eligibility Criteria To support your application for the C2 Tariff please provide evidence of the following Organisation is a direct customer of Horizon Power copy of Horizon Power bill voluntary Endorsement by the Commissioner of Taxation that organisation is exempt from income tax under Subdivision 50-B of the income Tax Assessment Act 1997 copy of Endorsement as an Income Tax Exempt Charitable Entity Organisation provides a public service available to any member of the public without discrimination have majority funding from one of these organisations copy of audited financial accounts or Annual Report 3. Declaration I hereby declare the organisation named above meets all eligibility criteria as required by Horizon Power to apply for the Name Position Signature please print Date 10/11.

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