FCC Form 1875 Incentive Payment Form

FCC Form 1875

REVERSE AUCTION (AUCTION 1001) INCENTIVE PAYMENT INSTRUCTIONS
FROM THE REVERSE AUCTION WINNING BIDDER
NOTICE: We have estimated that each response to this collection of information will take 6 hours for each winning
bidder and 3 hours for each third party payee, including both paper and on-line submissions. Our estimate includes
the time to read the instructions, look through existing records, gather and maintain the required data, and actually
complete and review the form or response. If you have any comments on this estimate, or on how we can improve
the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMDPERM, Paperwork Reduction Project (3060-1224), Washington, DC 20554. We will also accept your comments via
the Internet if your send them to [email protected]. Please DO NOT SEND COMPLETED APPLICATIONS 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 3060-1224, edition date January 2017.
Part 1: Reverse Auction Winning Bidder Information
1.a. Enter the Reverse Auction Winning Bidder Licensee name shown on the Closing and Channel Reassignment
PN.
1.b. Business Name of the Reverse Auction Winning Bidder as listed in the FCC’s Commission Registration System
(CORES), if different than the Licensee name entered in 1.a.
1.c. Taxpayer ID Number of the Reverse Auction Winning Bidder.
1.d. Enter the FCC Registration Number (FRN) of the Reverse Auction Winning Bidder that is associated with the
FIN in 1.e., below.
1.e. Enter a Station Facility ID Number for the Reverse Auction Winning Bidder Licensee shown on the Closing
and Channel Reassignment PN.
(The Facility ID Number is sometimes referred to as the Facility Identifier Number or the FIN, and is listed in
Federal Communications Commission’s (FCC or Commission) Licensing and Management System (LMS) at https://
enterpriseefiling.fcc.gov/dataentry/public/tv/publicFacilitySearch.html. This is NOT the call sign.)

1.f. For the Purpose of this Form the Contact Information for the Reverse Auction Winning Bidder.
Name: First.
Middle Initial
Last
Email Address:
Address: Street Number and Name
City.
State.
Zip Code.
Telephone Number:
1.g. Agent authorized to enter banking information in the FCC Commission Registration System (CORES) on
behalf of Reverse Auction Winning Bidder (“Authorized Agent”)
Authorized Agent
Name: First
Middle Initial
Last
CORES User Name:
Title for Authorized Agent:
E-mail Address of Authorized Agent:
Telephone Number of Authorized Agent:

Part 2: Recipient of the Reverse Auction Incentive Payment
2a.
To whom should the FCC disburse the Reverse Auction Incentive Payment for the Reverse Auction Winning
Bidder and FIN identified in Part 1? (Choose one.)
[ ] To the Reverse Auction Winning Bidder identified in Part 1 of this form.
[ ] To the Third Party Payee identified in Part 3 of this form.
Part 3: This part should be completed by the third party payee.
If there is no third party payee, then leave this part blank and skip directly to Part 4.
3.a. Name of third party payee.
3.b. Taxpayer ID Number of third party payee.

3.c. Certifications and Notarized Signature by Third Party Payee.
By signing this form, the third party payee:
(1) Agrees to indemnify and hold harmless the United States, the Commission, and any disbursing officer, from any
and all liability arising from the disbursement of incentive payments pursuant to these payment instructions
(2) Acknowledges and agrees that incentive payments pursuant to this form may be subject to offset pursuant to
applicable law for debts (owed to the Commission including its reporting components or the United States) by either
the Reverse Auction Winning Bidder or the third party payee designated by the Reverse Auction Winning Bidder;
(3) Acknowledges and agrees that incentive payments will not be made to (or for the benefit of) any reverse auction
winning bidder or other payee appearing on the U.S. Treasury's “Do Not Pay” portal;
(4) Acknowledges that any person who knowingly submits these payment instructions containing any
misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act and may be
subject to criminal penalties;
(5) Certifies that it is in compliance with all applicable statutes, regulations, rules and instructions entitling it, or
relating, to incentive payments; and
(6) Certifies that all information contained herein is true, accurate and complete and understands that the incentive
payment will be made from Federal funds and that any false claims, statements or documents, or concealment of a
material fact may be prosecuted under applicable Federal law and/or result in civil action.
Signed on behalf of the third party payee by:
Signature: ___________________________________________
Type or Print Name:
Type or Print Title:
Date Signed:
Acknowledgement
State of______________
County of_____________
On___________________________, before me, _______________________________________,
(date)
(notary)
personally appeared, _____________________________________________________________,
(signer)
personally known to me or proved to me on the basis of satisfactory evidence to be the
person whose name is subscribed to the within instrument and acknowledged to me that
he/she executed the same in his/her authorized capacity, and that by his/her signature
on the instrument the person or the entity upon behalf of which the person acted,
executed the instrument.
WITNESS my hand and official seal
_____________________________________________
(notary signature)
My Commission Expires: ______________________

Part 4: Financial Institution Information for Automated Clearing House (ACH) Payment
4.a. Name of the Financial Institution where the Reverse Auction Incentive Payment is to be sent:
Routing Transit Number:
Depositor Account Title:
Account Number:
Type of Account (choose one):

4.b. Address of the Financial Institution:
Street Number and Name
City
State
Telephone Number:

[ ] Checking

[ ] Savings

Zip Code

4.c. Attach to this form one of the following to confirm ownership of the bank account:
* A letter from the bank (see sample letter at the end of this form), or
* A redacted bank statement that confirms ownership of the bank account.
4.d. If the Reverse Auction Winning Bidder needs to request a freeze on payments, e.g., due to a change in banking
information, please send an e-mail to [email protected] at the FCC – informing the FCC of the freeze on
payments.
4.e. If the Reverse Auction Winning Bidder needs to submit a new Form because the financial information in Part 2
has changed, please send an e-mail to [email protected], informing the FCC of the need to send the FCC a
new Form.

Part 5: Certifications and Notarized Signature by Reverse Auction Winning Bidder
By signing this form, the Reverse Auction Winning Bidder identified in Part 1 of this form:
(1) Agrees to indemnify and hold harmless the United States, the Commission, and any disbursing officer, from any
and all liability arising from the disbursement of incentive payments pursuant to these payment instructions;
(2) Acknowledges and agrees that incentive payments pursuant to these payment instructions may be subject to offset
pursuant to applicable law for debts (owed to the Commission including its reporting components or the United States)
by either the Reverse Auction Winning Bidder or the third party payee designated by the Reverse Auction Winning
Bidder;
(3) Acknowledges and agrees that incentive payments will not be made to (or for the benefit of) any Reverse Auction
Winning Bidder or other payee appearing on the U.S. Treasury's “Do Not Pay” portal;
(4) Requests that, if the Reverse Auction Winning Bidder has designated a third party payee on this form, then the
Commission should disburse the incentive payment to the third party payee;
(5) Acknowledges that any person who knowingly submits these payment instructions containing any misrepresentation
or any false, incomplete or misleading information may be guilty of a criminal act and may be subject to criminal
penalties;
(6) Certifies that it is in compliance with all applicable statutes, regulations, rules and instructions entitling it, or
relating, to incentive payments; and
(7) Certifies that all information contained herein is true, accurate and complete and understands that the incentive
payment will be made from Federal funds and that any false claims, statements or documents, or concealment of a
material fact may be prosecuted under applicable Federal law and/or result in civil action.
Signed on behalf of the Reverse Auction Winning Bidder by:
Signature: ___________________________________________
Type or Print Name:
Type or Print Title:
Date Signed:
Acknowledgement
State of______________
County of_____________
On___________________________, before me, _______________________________________,
(date)
(notary)
personally appeared, _____________________________________________________________,
(signer)
personally known to me or proved to me on the basis of satisfactory evidence to be the
person whose name is subscribed to the within instrument and acknowledged to me that
he/she executed the same in his/her authorized capacity, and that by his/her signature on
the instrument the person or the entity upon behalf of which the person acted, executed
the instrument.
WITNESS my hand and official seal
_____________________________________________
(notary signature)
My Commission Expires: ______________________

After this form is completed, signed and notarized, send it to:
Federal Communications Commission
Travel & Operations Group, Attn: Chief of TOG
9300 East Hampton Drive
Capitol Heights, MD 20743

SAMPLE BANK ACCOUNT VERIFICATION LETTER
Do not send this sample to FCC.
The letter must be signed on bank letterhead by a bank officer, and it must mention: (1) Doing Business As (DBA) name
on account, (2) bank routing number, and (3) account number. Use this sample letter to make your request at the bank,
either in person or by phone.

May 5, 2005
To Whom It May Concern:
This letter is to inform you that John Doe, owner of Extra Wireless, Inc. (DBA: Extra Wireless), has a business account
with Bank of America. The routing number associated with the account is 012309999, the account number is
009991234567. The branch address for this account is:
1005 Westlake Blvd.
Tampa, FL 33609
813-555-1234
If you have any further questions, please do not hesitate to call me at 813-555-1357.
Regards,

Sarah Smith
Branch Manager