FCC Form 159-B, Remittance Advice Bill for Collection

FEDERAL COMMUNICATIONS COMMISSION

REMITTANCE ADVICE
BILL FOR COLLECTION
Bill Number

Applicant FRN

Approved by OMB
3060-0589
1 of __
1
Page __

FOR INQUIRIES CALL

Current Bill Date

1-202-418-1995
(Revenue and Receivable Operations Group)

Payable to:
Federal Communications Commission

Application Information:

Company Name
Company Address Line 1
Company Address Line 2

Send a copy of this bill to:
Federal Communications Commission
Revenue & Receivables Operations Group
P.O. Box 358365
Pittsburgh, PA 15251- 5365

City, State, Zip Code
Total Amount Due

Due Date

$2,417.64

9/14/2005

TOTAL AMOUNT DUE MUST BE RECEIVED BY

Payer FRN No.

Please Complete The Payer Information, FCC Registration Number (FRN) is required

Payer Name (if paying by credit card enter name as it appears on the card)
Address Line No. 1
Address Line No. 2
City

State

Zip Code

Day time Phone Number (include area code)
Reason For Bill:

Assess penalty for late reg fee
Call Sign/Other FCC
ID

820386

Payment Type Code

Quantity

Fee Due For (PTC)

Total Fee

0572

795934

$0.00

$1,934.11

0599

1

$0.00

$483.53

TOTAL DUE

FCC Code 1

795934

FCC Code 2

0

$2,417.64

Please choose a method of Payment and complete the section if paying by Credit Card
Payment Method:

CREDIT CARD
MASTERCARD

CHECK
DISCOVER

WIRE

IPAC

VISA

AMEX

ACCOUNT NUMBER________________________________________________________

MIPR

EXPIRATION DATE_____________________________________

I hereby authorize the FCC to charge my Credit Card for the service(s) / authorization(s) herein described.
AUTHORIZED SIGNATURE______________________________________________________________

DATE_____________________________________

FCC FORM 159B
IF PAYING BY CHECK, PLEASE WRITE YOUR BILL NUMBER ON YOUR REMITTANCE AND ATTACH A COPY OF THIS BILL TO YOUR PAYMENT TO ENSURE
PROPER CREDIT.