By my signature below, I certify that the information on my application form is true. By signing this application form, I agree to participate in any follow up survey in order to assure quality customer service and satisfactory use of my equipment. I understand that I am only allowed to receive one item or package of items per family household every five years. I become the owner of the items I receive and am responsible for the maintenance and warranty. I must use the voucher at an authorized dealer by the deadline listed on the form. I agree to pay any remaining cost that is not covered by the Telecommunications Access Iowa Voucher Program.