Form DTV-3 MANUFACTURER NOTICE OF INTENT DATA COLLECTION

Digital-to-Analog Converter Box Coupon Program OMB Control No. 0660-XXXX

Expiration Date: XX-XX-XXXX

NTIA DTV-3

MANUFACTURER NOTICE OF INTENT DATA COLLECTION¹

Name of Manufacturer:

___________________________________________

Name, Title, Address and Phone Number of Individual Responsible for this Submission:

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

Proposed Model Number____________ (Please submit a separate form for each model proposed for testing.)

Brief Description of the Proposed Converter Box (include a list of permitted as well as required features of the proposed converter box):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date that the proposed converter box will be available for testing^2*: ___________

NTIA shall treat the notices of intent received as business confidential and proprietary information and will not release information from the notices of intent to the public unless otherwise required by law

Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for

failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act (PRA), unless that

collection displays a currently valid Office of Management and Budget (OMB) control number.

1^* This sample form simply lists the required and permitted features that the manufacturer proposes to include in the converter box.

2^** Manufacturers must submit one converter box each to NTIA and to the FCC along with a copy of its test results.