Public Information Campaign (TV PSA)

Dear Public Service Director:
Please take a moment to complete the following information. It will help us determine the
kind of PSAs you want to receive in the future and ensure we will send you the correct
format. Thank you for your cooperation and support.
Can you accept digital files?  Yes  No
If yes, what file formats are best for you?
Would you like the digital files sent to you or do you prefer downloading them from a site:

 Sent to me  Downloading  Both
Can you accept digital collateral materials?  Yes  No
If yes, what file formats are best for you?

Title:
# Times Per Week Aired # Weeks Aired

“It’s so easy, even Kirk could do it.” :30
“C’mon George, kick the tires!”
:30
“Boldly go to socialsecurity.gov!”
:30
“No Check, Go Direct.”
:30
“Pointy Ears.”
:10
“Eminently logical.”
:10
“It makes the crankiest Klingon smile.” :10
“Chekov applied in his pajamas.”
:15

1-3
1-3
1-3
1-3
1-3
1-3
1-3
1-3

4-6
4-6
4-6
4-6
4-6
4-6
4-6
4-6

7-9
7-9
7-9
7-9
7-9
7-9
7-9
7-9

10-12
10-12
10-12
10-12
10-12
10-12
10-12
10-12

16+
16+
16+
16+
16+
16+
16+
16+

Name:
Call Letters:
Telephone:

Fax:

Address:
City:

State:

Zip:

1-3
1-3
1-3
1-3
1-3
1-3
1-3
1-3

4-6
4-6
4-6
4-6
4-6
4-6
4-6
4-6

7-9
7-9
7-9
7-9
7-9
7-9
7-9
7-9

10-12
10-12
10-12
10-12
10-12
10-12
10-12
10-12

16+
16+
16+
16+
16+
16+
16+
16+

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The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 1 minute
to read the instructions, gather the facts, and answer the questions. Send only comments
relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 212356401.