FCC Form 475-B Obscene, Profane, and/or Indecent Material Complaint For

Approved by OMB

3060-0874

Estimated time per response: 15 minutes

Federal Communications Commission

Washington, DC 20554

FCC Form 475B

Obscene, Profane, and/or Indecent Material Complaint Form

In order to process your complaint, the Commission needs the information marked below with an asterisk (*). Information not marked with an asterisk (*), if available, is also helpful.

Consumer Information:

* First Name:

M iddle Initial:

* Last Name:

* Post Office :

Box Number

* Street Address:

(Either Street Address OR

Post Office Box is required)

* City:

* State:

* Zip Code

E -Mail Address:

D aytime Telephone Number:

Program Information:

*(1) Date of Program: ________________

*(2) Time of Program: ______________

(3) Network: ______________________

*(4) Call Sign, Channel OR Frequency of the station on which you viewed/heard the material: ___________________

*(5) City and State where program was viewed or heard: __________________

(6) Name of Program or DJ/Personality/Song/Film: _____________________________

*Please describe the program in as much detail as possible in order to help the FCC determine whether the material was obscene, profane, or indecent (such as specific words, language, description of images, etc.):

You are not required to submit a transcript or an audiotape, videotape, CD/DVD or other recording in support of your complaint. Doing so, however, may help expedite the processing of your complaint. If you choose to submit a transcript you should send both this complaint and the transcript to The Federal Communications Commission, Investigations & Hearings Division/Enforcement Bureau, Room 4-C330, 445 12th Street, S.W., Washington, DC 20554. If you choose to submit an audiotape, videotape, CD/DVD or other recording, you should send both this complaint form and the recording to Federal Communications Commission, Investigations & Hearings Division/Enforcement Bureau, 9300 East Hampton Drive, Capitol Heights, MD 20743. Any documentation of the programming becomes part of the Commission's records and cannot be returned.

For additional information, please see our Obscene, Profane, and Indecent Broadcasts Fact Sheet at http://www.fcc.gov/cgb/consumerfacts/obscene.pdf.

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 complaints about obscene, profane and indecent programming. 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 (3060-0874), 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 3060-0874.

In addition, the information that consumers provide when filling out FCC Form 475B 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.

Revised January 2006