Application for Converter Box Coupons for Consumers usin

OMB Control No. 0660-XXXX

                        Expiration Date: XX-XX-XXXX

TV Converter Box Coupon Program Application Post Office Box Mail Receipt All information must be filled out. Please type or print clearly. This application is to apply for up to two $40 coupons which can be used towards the purchase of an eligible TV converter box.
Your Name:
Home Street Address:
City:		State:		ZIP Code:
If you use a post office box for mail receipt, please provide your post office address. You are required to provide one or more of the listed documents1 with your application to satisfy the requirement for proof of physical (home) residence listed above. Applications submitted without proper proof of physical residence will be denied.
Mailing Address
City:	State:		ZIP Code:
TV Service: Check the Statement below that best describes your household □ All or some of the TVs in my house are connected to one or more pay service, such as cable or satellite □ None of the TVs in my house are connected to one or more pay services, such as cable or satellite
Coupons Requested: How many coupons do you want? □ ONE -OR- □ TWO
By signing below, you declare that the above is true and correct. Signature: Date:

NOTE: This application contains collection of information requirements subject to the Paperwork Reduction Act (PRA).  Notwithstanding any other provision of 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 PRA unless that collection of information displays a currently valid OMB control number. The estimated response time for this survey is 30 minutes. The response time includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this estimate or any other aspects of this collection of information, including suggestions for

reducing the length of this questionnaire, to the National Telecommunications and Information Administration, Attn: Milton Brown, [email protected], (202) 482-1853.

1^*A valid driver’s license containing the applicant’s physical address; a utility bill (water, gas, electric, oil, cable, or landline telephone (i.e., not wireless or pager) bearing the applicant’s name and physical address and issued within the sixty (60) days immediately preceding the date the coupon application is submitted; a government-issued property tax bill for the applicant’s residence; an unexpired homeowner’s or renter’s insurance policy for the applicant’s residence; an unexpired residential lease or rental agreement with the applicant’s name and physical address. NTIA will only use this information for identification, verification and tracking purposes for the Coupon Program. This information will be collected and maintained in a manner meeting the highest level of security required for personally identifiable information.