Application for Converter Box Coupons for Nursing Home R

OMB Control No. 0660-XXXX

Expiration Date: XX-XX-XXXX

Section 1 Nursing home resident information
Name of Nursing Home Resident:
Name of Eligible Nursing Home:	SSN1:		Date of Birth:
Street Address of Eligible Nursing Home:
City:	State:		ZIP Code:
6. TV Service: Check the Statement below that best describes your situation □ All or some of the TVs that I own are connected to one or more pay service, such as cable or satellite □ None of the TVs that I own are connected to one or more pay services, such as cable or satellite By signing below, you declare that the above is true and correct.
Signature: Date:
Section 2 TO BE COMPLETED BY person designated to act on behalf of nursing home resident. SECTION 1 MUST ALSO BE COMPLETED.
Your Name:
SSN*:			Date of Birth:
Street Address:
City:	State:		ZIP Code:
Please enclose evidence that you are empowered to act on behalf of the Nursing Home Resident designated in Section 1, such as power of attorney or birth certificate indicating familial relationship. By signing below you declare that the above is true and correct.
Signature: Date:
Section 3 TO BE COMPLETED BY NURSING HOME OR OTHER SENIOR CARE FACILITY ADMINISTRATOR. SECTION 1 MUST ALSO BE COMPLETED.
Your Name:
SSN*:		Date of Birth:
Name of Eligible Nursing Home:
Street Address of Eligible Nursing Home:
City:	State:		ZIP Code:
Please enclose a copy of your facility’s operating license indicating your authorization to administer the Eligible Nursing Home. 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, mbrown@doc.gov, (202) 482-1816.

1 In accordance with the Privacy Act of 1974, disclosure of an individual’s social security number for purposes of this application process is voluntary; however, additional information to verify the resident’s identity will be solicited if the individual chooses not to disclose the SSN. Such additional processes may delay the resident’s receipt of the coupon.