Form FCC Form 1876 FCC Form 1876 Payment Instructions from the Eligible Entity Seeking Re

FCC Form 1876 (revised [date])

(Print Date: 190226105736152)

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 1876 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 you 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
Eligible Entity – Only Check One.
✔ Full Power, Class A and Multichannel Video Programming Distributors (MVPD)
❏ Translators & Low Power TV (LPTV)
❏ FM Stations
1.a. Call Sign, if applicable, as of date of this Form 1876
JPEG
Note: Do not resubmit this Form 1876 if call sign changes in the future.
1.b. Business Name of the Eligible Entity as listed in the FCC’s Commission Registration System (CORES)
ULS testdata 01302009
1.c. Taxpayer ID Number of the Eligible Entity (must be 9 digits).

208614543

1.d. Enter the FCC Registration Number (FRN) of the Eligible Entity that is associated with the Facility Identifier
Number (FIN)/ (FACID) or the MVPD File Number in 1.e., below.
0016216129
1.e. Enter the Broadcaster FIN or the MVPD File Number (include 5 (five) leading zeroes).
(The FIN is sometimes referred to as the Facility Identifier Number or the Facility ID Number, 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.)
47401
1.f. Contact Information for the Eligible Entity.
Name: First John Middle Initial s Last Doe
Email Address: [email protected]
Address: Street Number and Name 445 12th Street SW
City bethesda State DISTRICT OF COLUMBIA
Zip Code 20123-2422
Telephone Number: 234-234-2342 x2342

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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.
Note: Please ensure that all Authorized Agents are associated with the listed FRN in CORES.
AUTHORIZED AGENT 1 (required)
Name: First hua Middle Initial s Last lu
CORES User Name (email format): [email protected]
Title for Authorized Agent: TESTER
Additional Email of Authorized Agent for Correspondence (optional): [email protected]
Telephone Number of Authorized Agent: 301-418-2424 x 1234
AUTHORIZED AGENT 2 (optional)
Name: First Alan Middle Initial Last Muhealden
CORES User Name (email format): [email protected]
Title for Authorized Agent: DB Developer
Additional Email of Authorized Agent for Correspondence (optional):
Telephone Number of Authorized Agent: 202-418-7354

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Part 2: Financial Institution Information for Automated Clearing House (ACH) Payment
2.a.1. Financial Institution to send Reimbursement Payment to: BANCO POPULAR
Note: If multiple relocating Eligible Entities will be using the same bank account, we can expedite the processing
of FCC Form 1876 submissions if you also provide a list of all of the relocating Eligible Entities that will be using
the bank account. Please include the Entity Name, FRN, and FIN/ File #.
2.a.2. ACH Routing Transit No:

021502011

2.a.3. Name on Bank Account: John Doe
2.a.4. Is the Eligible Entity in Part 1.b. the owner of the account in 2.a.5.?

No

If the name on the bank account is different from name listed in Part 1.b., the Eligible Entity must either be the
owner of the bank account or there must be an ownership relationship between the Eligible Entity and the owner
of the bank account. If there is an ownership relationship then please briefly describe the nature of the ownership
relationship between the Eligible Entity and the owner of the bank account.
I am the owner

2.a.5. Account Number:

111111

2.a.6. Type of Account:

Checking

2.b. Attach to this Form 1876 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 1876), or
• A redacted bank statement that confirms ownership of the bank account
Note: The Complete bank account number must be displayed and the bank account supporting document must be
dated within six months of the signed date of this Form 1876.
2.c. 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.d. If the eligible entity needs to submit a new Form 1876 because the financial information in Part 2 has
changed, then please send an e-mail to [email protected], informing the FCC of the need to send the FCC
a new signed/notarized Form 1876 along with attachment to support 2.b.

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Part 3: Certifications and Notarized Signature by Eligible Entity
By signing this Form 1876, the Eligible Entity identified in Part 1 of this Form 1876:
(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 or stamp

_______________________________________________
(notary signature)
My Commission Expires:

___________________
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After this Form 1876 is completed, signed and notarized, send original to:
Federal Communications Commission
Travel & Operations Group
Attn: Chief of TOG, Tim Dates
9050 Junction Drive
Annapolis Junction, MD 20701
Remember to include the attachment required by Part 2.b. above.

SAMPLE BANK ACCOUNT VERIFICATION LETTER
INSTRUCTIONS:
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 ACH routing number, and (3) account number. Use this sample letter to make your request at the bank,
either in person or by phone.

January 5, 2019
To Whom It May Concern:
This letter is to inform you that Extra Wireless, Inc. (DBA: Extra Wireless), has a business account with Bank of
America. The ACH routing number associated with the bank 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