Application for Converter Box Coupons for Consumers usin

U.S. Department of Commerce OMB Control No. 0660-XXXX

National Telecommunications                    Expiration Date: XX-XX-XXXX and Information Administration

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 and physical address.
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.

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.