Converter Box Application Test Sample

Form Approved
OMB No. XXXX-XXXX

DIGITAL-TO-ANALOG

Department of Commerce

TELEVISION CONVERTER BOX
COUPON PROGRAM

Do you have a TV in your home that works with
the help of “rabbit ears” or a rooftop antenna?

If so, you should be aware of an important change in broadcasting coming in February 2009.
If you receive free TV using an antenna and your TV is not digital, you need to take action sometime
before February 17, 2009 so you can continue to receive programs after that date.

What’s this about? The Digital Television Transition and Public Safety Act of 2005 requires TV
stations to stop broadcasting in analog and to broadcast only in digital after February 17, 2009. The
digital transition will provide a better viewing experience for consumers and help emergency responders
protect your community.
The Act created the digitial-to-analog converter box coupon program for households wishing to use their
analog TVs after the transition. This Program allows US households to obtain up to two coupons, each
worth $40, that can be applied towards the cost of certain converter boxes. TVs connected to cable,
satellite, or other pay services do not need a converter box to receive programs after February 17, 2009.

What do I need to do? For each analog TV you own, you need to decide before February 17,
2009 how you would like to get programming after the change to digital.

What are my options?
1. Keep your TV and buy a converter box with coupons available from the US Government, or
2. Keep your TV and get cable, satellite or other paid TV services, or
3. Replace your TV with a digital TV.

How do I get a coupon? Apply online or by phone. You may also mail in or fax a Coupon
Application. You may request one coupon now and one later, but no more than two coupons per
household are allowed. Supplies are limited. Requests must be received by March 31, 2009. Contact
information is listed below.

ONLINE
www.DTV2009.gov
BY PHONE
1-888-DTV-2009
TDD/TTY: 1-8XX-XXX-XXXX
BY MAIL
PO Box 2000
Portland, OR 97208

A converter box is a new product
available beginning in 2008 that
makes analog-only TVs work after
February 17, 2009.

BY FAX
1-877-DTV-4ME2
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.

Form Approved
OMB No. XXXX-XXXX
Department of Commerce

DIGITAL-TO-ANALOG

TELEVISION CONVERTER BOX
COUPON PROGRAM

PO Box 2000, Portland, OR 97208-2000

Apply online:
www.DTV2009.gov
Apply by phone:
1-888-DTV-2009
Mail applications to:
PO Box 2000, Portland, OR 97208

SALLY B. SAMPLE
1234 SW ANY ST
ANY CITY, ST 00000-0000

Fax applications to:
1-877-DTV-4ME2
ALL APPLICATIONS MUST BE
SUBMITTED BY MARCH 31, 2009.
Expect to receive coupon(s) within 2 - 3
weeks of when you mail this Application.

COUPON APPLICATION All information must be filled out. Please type or print clearly.
1. Your Name and Address.
NAME
HOME
ADDRESS

First

Middle

Last

Street Address
City

Apt #
State

Zip

If the US Post Office does not deliver mail to your Home Address, provide as much information as
you can above regarding your Home Address and provide your Mailing Address below.
MAILING
ADDRESS
If different
Street Address - or - P.O. Box #
Apt #
than above
City

State

Zip

2. TV Service: Check the statement below that best describes your household.
All or some of the TVs in my house subscribe to one or more pay services, such as cable or satellite.
All of the TVs in my house receive their broadcast over-the-air using “rabbit ears” or an antenna.

3. Coupons Requested: How many coupons do you want?

ONE - OR -

TWO

4. Signature: By signing below, you declare that the above is true and correct.
Signature

Date

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.