Media Subscription Fee Exemption Declaration Form

Media Subscription Fee Exemption Declaration Form
Please complete this form to declare your eligibility for a media subscription fee exemption. All fields are required to process your declaration. Do not provide sensitive personal or financial information.
Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Residential Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Media Subscription
Eligibility Reason
Relationship to Subscriber (if not self)
Last 4 Digits of Subscription Account or Membership ID
Upload Supporting Document (e.g., proof of eligibility)
Cancelof
Should be Empty: