FCC Form 1876 Relocation Reimbursement Form

FCC Form 1876

PAYMENT INSTRUCTIONS FROM THE ELIGIBLE ENTITY
SEEKING REIMBURSEMENT
FROM THE TV BROADCASTER RELOCATION FUND
NOTICE: We have estimated that each response to this collection of information will take 6 hours, 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, AMD-PERM, Paperwork Reduction Project (3060-1223),
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 3060-1223, edition date January 2017.
Part 1: Eligible Entity Information
1.a. Enter the Licensee Name or MVPD Name as shown in LMS.
1.b. Business Name of the Eligible Entity as listed in the FCC’s Commission Registration System (CORES), if
different than the name entered in 1.a.
1.c. Taxpayer ID Number of the Eligible Entity.
1.d. Enter the FCC Registration Number (FRN) of the Eligible Entity that is associated with the FIN or the MVPD
File Number in 1.e., below.
1.e. Enter the Station Broadcaster Facility ID Number or the MVPD File Number.
(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. The
MVPD File Number is the file number assigned by the MVPD Dashboard to the MVPD’s FCC Form 399 for
which reimbursement from the Relocation Fund is being sought.)

1.f. Contact Information for the Eligible Entity.
Middle Initial
Name: First
Email Address:
Address: Street Number and Name
City
State
Telephone Number:

Last

Zip Code

1.g. Agent authorized to enter banking information in the FCC Commission Registration System (CORES) on
behalf of the Eligible Entity (“Authorized Agent”).
One name is required and a second name is optional.
Authorized Agent 1 (required)
Name: First
CORES User Name:
Title for Authorized Agent:
E-mail Address of Authorized Agent:
Telephone Number of Authorized Agent:

Middle Initial

Last

Authorized Agent 2 (optional)
Name: First
CORES User Name:
Title for Authorized Agent:
E-mail Address
Address of
of Authorized
Authorized Agent:
Agent:
E-mail
Telephone
Telephone Number
Number of
of Authorized
Authorized Agent:
Agent

Middle Initial

Last

Part 2: Financial Institution Information for Automated Clearing House (ACH) Payment
2.a. Name of the Financial Institution where the Eligible Entity Reimbursement Payment is to be sent:
Routing Transit Number:
Depositor Account Title:
Account Number:
Type of Account:

Checking
2.b. Address of the Financial Institution:
Street Number and Name
City
Telephone Number:

Savings

State

Zip Code

2.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.
2.d. If the eligible entity 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.
2.e. If the eligible entity 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 3: Certifications and Notarized Signature by Eligible Entity
By signing this form, the Eligible Entity 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 reimbursement payments pursuant to these payment instructions;
(2) Acknowledges and agrees that reimbursement 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 the Eligible Entity;
(3) Acknowledges and agrees that reimbursement payments will not be made to (or for the benefit of) any Eligible
Entity 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 reimbursement payments; and
(6) Certifies that all information contained herein is true, accurate and complete and understands that the
reimbursement 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 Eligible Entity 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
Remember to include the attachment required by item 2.c.
above.

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) 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