Form FCC Form 501 FCC Form 501 FCC Slamming Complaint Form 501

Instructions for completing FCC Slamming Complaint Form 501

Use the attached form to submit a slamming complaint to the Federal Communications

Commission (FCC). DO NOT INCLUDE THIS PAGE WHEN FILING.

“Slamming" is the illegal practice of changing a consumer's telephone service - local service, Intralata service (local toll), or Interlata service (long distance including state to state, in state and international long distance) - without permission.

You may file a complaint with the FCC electronically, by postal mail, by email, or by fax.

* Electronically: Use FCC Form 501. In order to file electronically you must be able to attach an electronic version of the phone bill(s) or a welcome letter showing the name of the alleged unauthorized phone company and the disputed charges.

When not filing electronically you must include this information:

your name, address and daytime phone number

phone number(s) that was allegedly slammed

your e-mail address, if applicable

the name of the phone company that you are complaining about

the name of your authorized LOCAL telephone service provider

the name of your authorized LONG DISTANCE telephone service provider

whether or not you have paid any of the disputed charges

a brief statement of what happened

COPIES of your phone bill showing the name of the alleged unauthorized

phone company and the disputed charges. You MUST attach a bill in order for your complaint to be processed.

You may send this information to us by:

* Postal Mail:

Federal Communications Commission

Consumer & Governmental Affairs Bureau

ATTN: Slam Team, Room CY A257A

445 12th Street, SW

Washington, D.C. 20554

* E-Mail: [email protected]

* Fax: (202) 418-0035, ATTN: Slam Team

For all other types of complaints please use FCC Form 475 – General Complaint Form

Federal Communications Commission Approved by OMB

3060-0968

Estimated time per response: 15 minutes

Slamming Complaint Form 501

For Slamming Complaints Only

In order for your Slamming complaint to be processed you MUST attach a copy of the phone bill(s) or a welcome letter/package, showing the name of the alleged unauthorized phone company and the disputed charges.

1. Today’s Date: _____________________________________________________

2. First Name: _____________________________________________________

3. Middle Initial _____________________________________________________

4. Last Name: _____________________________________________________

5. Street Address/Post Office Box Number:

_____________________________________________________

6. City: _____________________________________________________

7. State: _____________________________________________________

8. ZIP Code: _____________________________

9. Are you filing on behalf of a family member, client, company or organization?

Check one:  YES  NO

If yes, please provide their information:

9a. First Name /Company Name: __________________________________________________________________

9b. Middle Initial: ________________________________________________

9c. Last Name: ________________________________________________

9d. Your relationship to this person or your title in the company/organization:

________________________________________________

9e. Street Address: ________________________________________________

9f. City: ________________________________________________

9g. State: _________________ 9h. ZIP Code: ___________________

FCC Form 501

October 2004

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10. Is this complaint about a (check one)

 Residential (Home) Telephone Service

 Business (Commercial) Telephone Service

11. List all Telephone Numbers (Maximum of 6) -- including Area Codes, that you

claim were slammed:

11a. ( ) ( _ _ _ - _ _ _ _ ) ( ) (area code) (phone number) (extension) 11b. ( ) ( _ _ _ - _ _ _ _ ) ( ) (area code) (phone number) (extension) 11c. ( ) ( _ _ _ - _ _ _ _ ) ( ) (area code) (phone number) (extension) 11d. ( ) ( _ _ _ - _ _ _ _ ) ( ) (area code) (phone number) (extension)

11e. ( ) ( _ _ _ - _ _ _ _ ) ( ) (area code) (phone number) (extension)

11f. ( ) ( _ _ _ - _ _ _ _ ) ( ) (area code) (phone number) (extension)

12. Your Daytime Telephone Number

( ) ( _ _ _ - _ _ _ _ ) ( ) (area code) (phone number) (extension)

13. Name of your authorized LOCAL telephone service provider:

_________________________________________________________________

14. Name of your authorized LONG DISTANCE telephone service provider that the service

was changed from:

_____________________________________________________

15. Name of the company that you are complaining about:

_________________________________________________________________

16. Are you back with your authorized telephone company? Check one:  YES or  NO

17. Amount of charges you are disputing $________________

18. Have you paid any of the disputed charges? Check one:  YES or  NO

19. Did the billing company adjust or refund the disputed charges? Check one:  YES or  NO

20. If yes, how much was the adjustment or refund? $______________________________

21. Briefly explain what happened. Please include dates whenever possible.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_

FCC Form 501

October 2004

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_____________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

REMEMBER: You MUST attach a bill or welcome letter from the unauthorized company in order for your complaint to be processed.

Federal Communications Commission

Consumer and Governmental Affairs Bureau

445 12th Street SW

Washington, DC 20554

FCC NOTICE REQUIRED BY THE PRIVACY ACT AND PAPERWORK REDUCTION ACT

The Federal Communications Commission is authorized under the Communications Act of 1934, as amended, to collect the personal information that we request in this form. This form is used for slamming disputes between consumers and telecommunications carriers to be brought before appropriate state commissions, or this Commission in cases where the state has not opted to administer our rules, rather than to authorized carriers. If we believe there maybe a violation or potential violation of a statute, FCC regulation, rule or order, your complaint may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing or implementing the statute, rule, regulation, or order.

The public reporting for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the required data, and completing and reviewing the collection of information. If you have any comments on this burden estimate, or how we can improve the collection and reduce the burden it causes you, please write to the Federal Communications Commission, AMD-PERM, Paperwork Reduction Project (3060-0968), Washington, DC 20554. We will also accept your comments regarding the Paperwork Reduction Act aspects of this collection via the Internet if you send them to [email protected]. PLEASE DO NOT SEND YOUR COMPLETED FORMS TO THIS ADDRESS.

Remember - You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-0968.

In addition, the information that consumers provide when filling out FCC Form 501 is covered by the system of records notice, FCC/CGB-1, Informal Complaints and Inquiries File (Broadcast, Common Carrier, and Wireless Telecommunications Bureau Radio Services). The Commission is authorized to request this information from consumers under 47 U.S.C. 206, 208, 301, 303, 309(e), 312, 362, 364, 386, 507, and 51; and 47 CFR 1.711 et seq.

Under this system of records notice, FCC/CGB-1, the FCC may disclose information that consumers provide as follows: when a record in this system involves a complaint against a common carrier, the complaint is forwarded to the defendant carrier who must, within a prescribed time frame, either satisfy the complaint or explain to the Commission and the complainant its failure to do so; where there is an indication of a violation or potential violation of a statute, regulation, rule, or order, records from this system may be referred to the appropriate Federal, state, or local agency responsible for investigating or prosecuting a violation or for enforcing or implementing the statute, rule, regulation, or order; a record from this system may be disclosed to a Federal agency, in response to its request, in connection with the hiring or retention of an employee, the issuance of a security clearance, the reporting of an investigation of an employee, the letting of a contract, or the issuance of a license, grant or other benefit; a record on an individual in this system of records may be disclosed, where pertinent, in any legal proceeding to which the Commission is a party before a court or administrative body; a record from this system of records may be disclosed to the Department of Justice or in a proceeding before a court or adjudicative body when: the United States, the Commission, a component of the Commission, or, when represented by the government, an employee of the Commission is a party to litigation or anticipated litigation or has an interest in such litigation, and the Commission determines that the disclosure is relevant or necessary to the litigation; a record on an individual in this system of records may be disclosed to a Congressional office in response to an inquiry the individual has made to the Congressional office; and a record from this system of records may be disclosed to GSA and NARA for the purpose of records management inspections conducted under authority of 44 U.S.C. 2904 and 2906. Such disclosure shall not be used to make a determination about individuals.

In each of these cases, the FCC will determine whether disclosure of the information in this system of records notice is compatible with the purpose for which the records were collected. Furthermore, information in this system of records notice is available for public inspection after redaction of information that could identify the complainant or correspondent, i.e., name, address and/or telephone number.

THE FOREGOING NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. SECTION 552a(e)(3) AND THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

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FCC Form 501

October 2004

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