Form DTV-1 RETAILER DATA COLLECTION FORM

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

Expiration Date: XX-XX-XXXX

NTIA DTV-2 Form

RETAILER DATA COLLECTION FORM

To Participate the NTIA Coupon Program

For the Digital-to-Analog Converter Box

By signing this statement,

Legal Business Name: ______________________________________________

Doing Business As: ________________________________________________

Corporate Address: ________________________________________________

City: ___________________ State: ____ Zip: __________

Person authorized to sign agreements,

(Name and Title) __________________________________________________

Contact Telephone: ___________________________

Contact email: _______________________________

Certifies to the following:

1) Retailer has been engaged in the consumer electronics retail business for at least one year and has completed a Central Contractor Registration. (CCR #________________)

(2) Retailer has in place systems or procedures that can be easily audited as well as systems that can provide adequate data to minimize fraud and abuse in retail redemption and government payment for coupons;

(3) Retailer agrees to have coupons box sales audited at any time during the term of participation in the coupon program by the U. S. Government or an independent auditor at no expense to the retailer;

(4) Retailer will provide NTIA electronically with redemption information and payment receipts related to coupons used in the purchase of converter boxes, specifically tracking each serialized coupon by number with a corresponding converter box purchase; and

(5) Retailer will only accept coupons and receive payment resulting from purchases made for coupon-eligible converter boxes as defined in the NTIA Final Rule.

Name of Officer Title 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.

NTIA will release to the public a list of retailers certified to sell converters boxes.