TV Converter Box Coupon Program Website

Apply for a Coupon

To apply for the coupon, please supply the following information.

*Items marked with an asterisk are required.

IMPORTANT: Coupons will expire within 90 days of the date they are mailed.

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1. Your Name and Address

Name


First*		M.I.		Last*

Home Address


Address*		Apt#

				-
City*		State*		Zip* Zip + 4

The U.S. Postal Service does not deliver mail to my home address.

By selecting the checkbox above, you certify that your home does not have an address that receives U.S. Postal Service.

Please provide as much information as you can above regarding your Home Address AND provide your Mailing Address below.


Mailing Address*		Suite #

				-
City*		State*		Zip* Zip + 4

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.
None of the TVs in my house subscribe to one or more pay services, such as cable or satellite.

3. Coupons Requested

How many coupons do you want?* One - or -Two

4. Signature

By checking this box, you declare that the above is true and correct.*

Please enter the words you see in the distorted image below, in order and separated by a space.
If you cannot read the words below, please click here to receive a new challenge.

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** the submittal process may take a few minutes **

Form Approved OMB No. 0660-0024

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, U.S. Department of Commerce, USA.gov