FCC Form 2100, Sch Ownership Report for Noncommercial Broadcast Stations

DRAFT – NOT YET APPROVED BY OMB

FCC Form 2100, Schedule 323-E

Ownership Report For Noncommercial Broadcast Stations

FRN:0123456789

Section I – General Information

1. Respondent	FRN	Name
	[FRN]	[respondent name]
	Street Address		City (and Country if non-U.S. address)	State (“NA” if non-U.S. address)	Zip Code	Phone	Email
	[street address 1] [street address 2]	[city]		[state]	[zip]	[phone]	[email]

2. Contact Representative	Name				Organization
	[name]				[organization]
	Street Address		City (and Country if non-U.S. address)	State (“NA” if non-U.S. address)		Zip Code		Phone	Email
	[street address 1] [street address 2]		[city]	[state]		[zip]		[phone]	[email]

3. Respondent and Report Information	(a) Provide the following information about the Respondent:
	Relationship to stations/ permits	Licensee Permittee (non-biennial reports only) Entity required to file a Form 323-E because it holds an attributable interest in one or more Licensees or, in the case of a non-biennial report, Permittees
	Control of Respondent	Is the Respondent’s governing board (or other governing entity) directly or indirectly under the control of another entity? If Yes, each such controlling entity is considered to have an attributable interest in the Respondent, and a separate Form 2100, Schedule 323-E must be submitted for each such controlling entity.	Yes No
	(b) Provide the following information about this report:
	Purpose	(1) Biennial [file number] (2) Validation and resubmission of a previously filed biennial report (certifying no change from previous report) Provide file number of report that is being validated and resubmitted: (3) Transfer of control or assignment of license/permit (4) Report by Permittee filing within 30 days after the grant of a construction permit for a new noncommercial AM, FM, or full power television broadcast station (5) Report filed by Permittee in conjunction with Permittee’s application for a station license [file number] (6) Certification of accuracy of an initial or post-consummation ownership report filed by Permittee in conjunction with Permittee’s application for a station license Provide file number of report being certified: (7) Amendment to a previously filed ownership report Submit an Exhibit listing, by Section and Question Number, the portions of the previous report that are being revised.
	“As of” date	[date] All of the information furnished in this report is accurate as of the following date (mm/dd/yyyy): When filing a biennial ownership report or validating and resubmitting a prior biennial ownership report, this date must be Oct. 1 of the year in which this report is filed.

4. Licensee(s)/ Permittee(s) and Stations(s)/ Permit(s)	Respondent is filing this report to cover the following Licensee(s)/Permittee(s) and license(s)/permit(s):
	Licensee/Permittee Name				FRN
	[licensee name]				[FRN]
	Fac. ID No.	Call Sign	City	State	Service
	[Fac. ID No.]	[call sign]	[city]	[state]	[service]

Section II-A – Non-Biennial Ownership Information

1. 47 C.F.R. Section 73.3613 Documents	Licensee/Permittee Respondents should list all contracts and other instruments required to be filed pursuant to 47 C.F.R. Section 73.3613 for the facility or facilities listed on this report. If the agreement is a network affiliation agreement, check the appropriate box. Otherwise, select “Other.” Non-Licensee/Permittee Respondents should select “Not Applicable” in response to this question.		Not Applicable
	Document Information
	Description of contract or instrument	[description of contract or instrument]
	Parties to contract or instrument	[parties to contract or instrument]
	Date of execution (mm/yyyy)	[date of execution]
	Date of expiration (mm/yyyy)	[date of expiration] No expiration date
	Agreement type (check all that apply)	[agreement type] Network Affiliation Agreement Other Indicate agreement type:

2. Ownership Interests	(a) Ownership Interests. This Question requires Respondents to enter detailed information about ownership interests by generating a series of subforms. Answer each question on each subform. The first subform listing should be for the Respondent itself. If the Respondent is not a natural person, also list each of the officers, members of the governing board, stockholders, and any other persons or entities with a direct attributable interest in the Respondent pursuant to the standards set forth in 47 C.F.R. Section 73.3555. (A “direct” interest is one that is not held through any intervening companies or entities.) List each interest holder with a direct attributable interest in the Respondent separately. Leave the percentage of total assets (Equity Debt Plus) field blank for an interest holder unless that interest holder has an attributable interest in the Respondent solely on the basis of the Commission’s Equity Debt Plus attribution standard, 47 C.F.R. Section 73.3555, Note 2(i). In the case of vertical or indirect ownership structures, list only those interests in the Respondent that also represent an attributable interest in the Licensee(s) or Permittee(s) for which the report is being submitted. Entities that are part of an organizational structure that includes holding companies or other forms of indirect ownership must file separate ownership reports. In such a structure do not report, or file a separate report for, any interest holder that does not have an attributable interest in the Licensee(s) or Permittee(s) for which the report is being submitted. Please see the Instructions for further detail concerning interests that must be reported in response to this question. The Respondent must provide an FCC Registration Number for each interest holder reported in response to this question. Please see the Instructions for detailed information and guidance concerning this requirement.
	Ownership Information
	FRN		[FRN]
	Name		[name]
	Address		Street 1		[street 1]
			Street 2		[street 2]
			City		[city]
			State (“NA” if non-U.S. address)		[state]
			Zip/Postal Code		[zip]
			Country (if non-U.S. address)		[country]
	Listing Type		Respondent Other interest holder
	Positional Interests (check all that apply)		[interest type] Officer Parent entity Member of governing board (or other governing entity) Other Specify interest type:
	Principal Profession or Occupation		[profession]		N/A (entity)
	By Whom Appointed or Elected		[appointed/elected by]		N/A (entity)
	Interest Percentages (enter percentage values from 0.0 to 100.0)		Voting		[voting]
			Total assets (Equity Debt Plus)		[total assets]
	Does interest holder have an attributable interest in one or more broadcast stations that do not appear on this report?				Yes No
	(b) Respondent certifies that any interests, including equity, financial, or voting interests, not reported in response to Question 2(a) are non-attributable. If “No,” submit as an exhibit an explanation.						Yes No
	(c) Is Respondent seeking an attribution exemption for any officer or member of the governing board (or other governing entity) with duties wholly unrelated to the Licensee(s) or Permittee(s)? If “Yes,” complete the information in the required fields and submit an Exhibit fully describing that individual’s duties and responsibilities, and explaining why that individual should not be attributed an interest.						Yes No
	Attribution Exemptions
	Name	[name]		Title		[title]

Section II-B – Biennial Ownership Information

1. 47 C.F.R. Section 73.3613 Documents	Licensee Respondents that hold authorizations for one or more full power television, AM, and/or FM stations should list all contracts and other instruments required to be filed pursuant to 47 C.F.R. Section 73.3613 for the facility or facilities listed on this report. If the agreement is a network affiliation agreement, check the appropriate box. Otherwise, select “Other.” Non-Licensee Respondents should select “Not Applicable” in response to this question.		Not Applicable
	Document Information
	Description of contract or instrument	[description of contract or instrument]
	Parties to contract or instrument	[parties to contract or instrument]
	Date of execution (mm/yyyy)	[date of execution]
	Date of expiration (mm/yyyy)	[date of expiration] No expiration date
	Agreement type (check all that apply)	Network Affiliation Agreement [agreement type] Other Indicate agreement type:

2. Ownership Interests	(a) This Question requires Respondents to enter detailed information about ownership interests by generating a series of subforms. Answer each question on each subform. The first subform listing should be for the Respondent itself. If the Respondent is not a natural person, also list each of the officers, members of the governing board (or other governing entity), stockholders, and any other persons or entities with a direct attributable interest in the Respondent pursuant to the standards set forth in 47 C.F.R. Section 73.3555. (A “direct” interest is one that is not held through any intervening companies or entities.) List each interest holder with a direct attributable interest in the Respondent separately. Leave the percentage of total assets (Equity Debt Plus) field blank for an interest holder unless that interest holder has an attributable interest in the Respondent solely on the basis of the Commission’s Equity Debt Plus attribution standard, 47 C.F.R. Section 73.3555, Note 2(i). In the case of vertical or indirect ownership structures, list only those interests in the Respondent that also represent an attributable interest in the Licensee(s) for which the report is being submitted. Entities that are part of an organizational structure that includes holding companies or other forms of indirect ownership must file separate ownership reports. In such a structure do not report, or file a separate report for, any interest holder that does not have an attributable interest in the Licensee(s) for which the report is being submitted. Please see the Instructions for further detail concerning interests that must be reported in response to this question. The Respondent must provide an FCC Registration Number for each interest holder reported in response to this question. Please see the Instructions for detailed information and guidance concerning this requirement.
	Ownership Information
	FRN	[FRN]
	Name	[name]
	Address	Street 1	[street 1]
		Street 2	[street 2]
		City	[city]
		State (“NA” if non-U.S. address)	[state]
		Zip/Postal Code	[zip]
		Country (if non-U.S. address)	[country]
	Listing Type	Respondent Other interest holder
	Positional Interests (check all that apply)	[interest type] Officer Parent entity Member of governing board (or other governing entity) Other Specify interest type:
	Principal Profession or Occupation	[profession]	N/A (entity)
	By Whom Appointed or Elected	[appointed/elected by]	N/A (entity)
	Citizenship, Gender, Ethnicity, and Race Information (Natural Persons Only)	N/A (entity)
		Citizenship	[citizenship]
		Gender	Male Female
		Ethnicity	Hispanic or Latino Not Hispanic or Latino
		Race (Check all categories that apply to the individual being reported)	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
	Tribal Nation or Tribal Entity	Yes
	Interest Percentages (enter percentage values from 0.0 to 100.0)	Voting	[voting]
		Equity	[equity]
		Total assets (Equity Debt Plus)	[total assets]
	Does interest holder have an attributable interest in one or more broadcast stations that do not appear on this report?		Yes No
	(b) Respondent certifies that any interests, including equity, financial, or voting interests, not reported in response to Question 2(a) are non-attributable. If “No,” submit as an exhibit an explanation.			Yes No

(c) Is Respondent seeking an attribution exemption for any officer or member of the governing board (or other governing entity) with duties wholly unrelated to the Licensee(s)? If “Yes,” complete the information in the required fields and submit an Exhibit fully describing that individual’s duties and responsibilities, and explaining why that individual should not be attributed an interest.				Yes No
Attribution Exemptions
Name	[name]	Title	[title]

3. Organizational Chart (Licensees Only)

Attach a flowchart or similar document showing the Licensee’s vertical ownership structure including the Licensee and all entities that have attributable interests in the Licensee. Licensees with a single parent entity may provide a brief explanatory textual Exhibit in lieu of a flowchart or similar document. Licensees without parent entities should so indicate in a textual Exhibit. Non-Licensee Respondents should select “N/A” in response to this question.

Not Applicable

Section III – Certification

[title] I certify that I am (official title) [respondent] of (exact legal title or name of Respondent) and that I have examined this report and that to the best of my knowledge and belief, all statements in this report are true, correct and complete.
Signature	[signature]
Date (mm/dd/yyyy) (When filing a biennial ownership report, date of signature below must be no earlier than Oct. 1 of the filing year.)	[date]
Telephone Number (Include area code)	[telephone number]

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1)), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503).