FCC Form 611-T FCC Wireless Telecommunications Bureau Annual Report Rel

FCC 611-T FEDERAL COMMUNICATIONS COMMISSION Approved by OMB

3060-1092

Est. Avg. Burden

Per Response: 6 Hrs.

Information and Instructions

FCC Wireless Telecommunications Bureau

Annual Report Related to Eligibility for Designated Entity Benefits

NOTICE TO INDIVIDUALS REQUIRED BY THE PRIVACY ACT OF 1974 AND

THE PAPERWORK REDUCTION ACT OF 1995

We have estimated that each response to this collection of information will take on average 6 hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain 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, Washington, DC 20554, Paperwork Reduction Project (3060-1092). We will also accept your comments via the Internet if you send them to [email protected]. Please do not send completed application forms to this address.

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 with this notice. This collection has been assigned OMB control number 3060-1092.

The FCC is authorized under the Communications Act of 1934, as amended, to collect the personal information we request in this form. We will use the information you provide to determine whether the Application/Notification is in the public interest. If we believe there may be a violation or potential violation of a statute, FCC regulation, rule or order, your application may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing or implementing the statute, rule, regulation or order. In certain cases, the information in your application may be disclosed to the Department of Justice or a court or adjudicative body when (a) the FCC; or (b) any employee of the FCC; or (c) the United States Government, is a party to a proceeding before the body or has an interest in the proceeding.

All parties and entities doing business with the Commission must obtain a unique identifying number called the FCC Registration Number (FRN) and supply it when doing business with the Commission. Failure to provide the FRN may delay the processing of the application. This requirement is to facilitate compliance with the Debt Collection Improvement Act of 1996 (DCIA). The FRN can be obtained electronically through the FCC webpage at http://www.fcc.gov or by manually submitting FCC Form 160. FCC Form 160 is available from the FCC’s web site at http://www.fcc.gov/formpage.html, by calling the FCC’s Forms Distribution Center 800-418-FORM (3676), or from Fax Information System by dialing (202) 418-0177.

This 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. 3507.

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General Instructions for Wireless Telecommunications Bureau Annual Report Related To Eligibility for Designated Entity Benefits

Purpose of Form

FCC Form 611-T is used by designated entity licensees to file an annual report, pursuant to section 1.2110(n) of the Commission’s Rules, related to eligibility for designated entity benefits.

Who Must File and What Must be Filed

Each designated entity licensee must file with the Commission an annual report no later than September 30 of each year for each individual license it holds that was acquired using designated entity benefits and that, as of August 31 of the year in which the report is due, remains subject to designated entity unjust enrichment requirements (a “designated entity license”). If, during the reporting year, a designated entity has assigned or transferred a designated entity license to another designated entity, the designated entity that holds the designated entity license on September 30 of the year in which the application for the transaction is filed is responsible for filing the annual report.

Annual Report

The annual report, which should be filed as an attachment to this Form 611-T, shall include:

• A list and summary of all agreements and arrangements (including proposed agreements and arrangements) that relate to eligibility for designated entity benefits for each designated entity license covered by the annual report. Similar types of agreements and arrangements should be listed together in clearly identified categories, such as, but not limited to, categories covering credit and loan, management, leasing, equipment, tower and facilties agreements and arrangements. This list and summary must include:

• The parties (including affiliates, controlling interests, and affiliates of controlling interests) to each agreement or arrangement, as well as the dates on which the parties entered into each agreement or arrangement.

• The dates on which any agreement or arrangement will terminate.

• An indication of which agreements or arrangements are new or have been modified since the designated entity’s previous Annual Report filing.

• A disclosure and discussion of the specific provisions of any agreement or arrangement that could affect the licensee’s eligibility for designated entity benefits.

• An explanation of which licenses, if the annual report covers more than one license, are affected by each agreement or arrangement.

• Information regarding the designated entity’s progress in meeting the applicable construction requirements for the license(s).

• Information regarding the services provided or planned to be provided using the license(s).

• Information regarding the number of subscribers served in the license(s) area.

• If applicable, any other information that might affect the licensee’s designated entity status.

A designated entity need not list and summarize on its annual report the agreements and arrangements otherwise required to be included if it has already filed that information with the Commission, and the information on file remains current. In such a situation, the designated entity must instead include in its annual report both the ULS file number of the report or application containing the current information and the date on which that information was filed.

Information Current and Complete

Information filed with the FCC must be kept current and complete. Parties to the application must notify the FCC regarding any substantial and significant changes in the information furnished in the application. See Section 1.65 of the Commission’s Rules. The requirement to update the annual report will be in effect until the report is changed to “accepted” status in the Commission’s Universal Licensing System (ULS).

Applicable Rules and Regulations

The Licensee should obtain the relevant parts of the Commission’s Rules, which are located in Part 47 of the Code of Federal Regulations (CFR). Copies of Part 47 CFR may be purchased by contacting the Superintendent of Documents, Government Printing Office, Washington, DC 20402, by calling (202) 512-1800 or by accessing the Government Printing Office’s website at http://www.access.gpo.gov.

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Application Fees and Filing Locations

No application fee is required with this form.

Assistance with Completing this Form

For additional information or assistance, you may visit the web at http://esupport.fcc.gov. You may also contact the FCC Support Center at (877) 480-3201 (TTY 717-338-2824).

Technical Assistance for Electronic Filers

For technical assistance with filing electronically, contact the Wireless Telecommunications Bureau Technical Support line at (877) 480-3201.

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Instructions for FCC Form 611-T

Annual Report Related To Eligibility for Designated Entity Benefits

Purpose of Filing

Item 1a Indicate the purpose for which this Application is being submitted by checking the appropriate block from the available selection of purposes (only one purpose may be selected).

Item 1b If the filing is an amendment (response to Item 1a is ‘AM’) or withdrawal (response to Item 1b is ‘WD’) of a currently pending Application, provide the File Number of the original Application. This information can be obtained by using the ULS Application Search or contacting the FCC at (877) 480-3201 (TTY 717-338-2824).

Licensee Information

Items 2 through 14 identify the Licensee.

FCC Registration Number (FRN)

Item 2 Enter your ten-digit FRN assigned by the Commission Registration System (CORES). The FRN is a unique identifier for everyone doing business with the Commission. Failure to provide the FRN will prevent the Commission from processing the application. The FRN can be obtained electronically through the FCC webpage at http://wireless.fcc.gov/uls/ (Select FCC Registration Number (FRN) Commission Registration System (CORES)) or by manually submitting FCC Form 160. FCC Form 160 is available for downloading from http://www.fcc.gov/formpage.html, by calling the FCC's Forms Distribution Center at (800) 418-3676, or the FCC’s Fax Information System by dialing (202) 418-0177.

Entity

Item 3 This item indicates the legal entity type of the Licensee. Select only one of the following options - Individual, Corporation, Unincorporated Association, Trust, Government Entity, Consortium, General Partnership, Limited Liability Company, Limited Liability Partnership, Limited Partnership, or Other. When selecting ‘Other’, provide a description of the legal entity.

Licensee Name

Items 4 and 5 If Item 3 indicates the Licensee is an ‘Individual’ enter the individual name in Item 5. Otherwise, enter the name of the legal entity in Item 4. Note: The full legal name is required for these items.

Item 6 If completing Item 4 (entity name), enter the contact person for the Licensee. Note: This item is optional.

Address

Items 7-14 Complete this section as follows:

• Either a PO Box (Item 7) or a Street Address (Item 8) is required. Both may be provided.

• City, State and Zip Code are required (Items 9-11).

• Telephone Number (including area code) is required (Item 12).

• FAX Number and E-Mail Address are optional (Items 13-14).

Refer to Main Form Instructions, Appendix I, for a list of valid state, jurisdiction, and area abbreviations.

Failure to respond to FCC correspondence sent to the address of record may result in dismissal of an Application/Notification, liability for forfeiture, or revocation of an authorization. (See Section 1.934(c) of the Commission’s Rules).

Demographics (Optional)

Item 15 The information is optional and is requested for informational purposes only. Responses to this item will in no way affect processing of Applications/Notifications.

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Licensee Contact Information

Contact Name & Address (If other than Licensee)

Items 16-26 These items identify the contact representative for the Licensee. This is usually the Licensee itself, the headquarters office of a large company, the law firm or other representative of the Licensee, or the person or company that prepared or submitted the Application on behalf of the Licensee. If there is a question about the Application, an FCC representative may communicate with the Licensee’s contact representative.

Completion of the Licensee Contact Information section is required.

If, however, the Licensee Contact Information is the same in all respects as the Licensee Information provided in Items 1-14, check the box located above Item 16 and do not complete the remaining items in this section.

If the Licensee Contact Information is not the same as the Licensee Information, then you must provide the information and complete this section as follows:

• Either the Individual Name (Item 16) or the Company Name (Item 17) is required.

• If Individual Name (Item 16) is completed, then Company Name (Item 17) and Attention To (Item 18) are optional.

• If Company Name (Item 17) is completed, then either an Individual Name (Item 16) or Attention To (Item 18) is required.

• Either a PO Box (Item 19) or a Street Address (Item 20) is required. Both may be provided.

• City, State and Zip Code are required (Items 21-23).

• Telephone Number (including area code) is required (Item 24).

• FAX Number and E-Mail Address are optional (Items 25-26).

Licensee Certification Statements

By signing this form, the Licensee certifies that the statements listed in this section are true, complete, correct, and made in good faith. General Certification (4) is required for licenses for spectrum that is required by Sections 6103, 6401-6403 of the Middle Class Tax Relief and Job Creation Act of 2012, codified at 47 U.S.C. §§ 309, 1413, 1451-1452, to be assigned by a system of competitive bidding under 47 U.S.C. § 309(j) (e.g. radio service AH (AWS-H Block at 1915-1920 MHz and 1995-2000 MHz), radio service AT (AWS-3, 1695-1710 MHz, 1755-1780 MHz and 2155-2180 MHz), and radio service WT (600 MHz Band)). For purposes of this certification, the term “reasons of national security” means matters relating to the national defense and foreign relations of the United States..

Items 27-29 These items must be completed. To be acceptable for filing, the Application (or Amendment or Withdrawal of a pending Application) must be signed in accordance with Part 1 of the FCC Rules. The party signing must be a person authorized to sign the Application. A paper original of the Application must bear an original signature; neither a rubber-stamped nor photocopied signature is acceptable. For a Licensee filing electronically via ULS, the electronic signature shall consist of the name of the individual typed on the Application as a signature.

License Authorization(s) To Be Included in the Filing

Item 30 In this column, list the Call Sign(s) of the licenses that are associated with the Application. Call signs are located on FCC Authorizations.

Item 31 In this column, list the Radio Service Code for each Call Sign listed in Item 30. The Radio Service Code is a 2-letter code and is located on FCC authorizations.

Item 32 In this column, provide the initial grant date of the license(s). The initial grant date is the date that the license was originally granted by the Commission after an auction, even if the license was acquired in the secondary market. The initial grant date is not the date on which the Commission granted an assignment or transfer of control of the license.

Item 33 In this column, indicate which designated entity benefits are associated with the license(s). Place a “B” in the field if the license was granted with a bidding credit, a “C” if the license is a closed bidding or entrepreneur license, and/or an “I” if the license has installment payments.

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Appendix I

STATE TABLE

Abbreviations for States, Jurisdictions, and Areas

AL Alabama

AK Alaska

AZ Arizona

AR Arkansas

CA California

CO Colorado

CT Connecticut

DE Delaware

DC District of Columbia

FL Florida

GA Georgia

GM Gulf of Mexico

HI Hawaii

ID Idaho

IL Illinois

IN Indiana

IA Iowa

KS Kansas

KY Kentucky

LA Louisiana

ME Maine

MD Maryland

MA Massachusetts

MI Michigan

MN Minnesota

MS Mississippi

MO Missouri

MT Montana

NE Nebraska

NV Nevada

NH New Hampshire

NJ New Jersey

NM New Mexico

NY New York

NC North Carolina

ND North Dakota

OH Ohio

OK Oklahoma

OR Oregon

PA Pennsylvania

RI Rhode Island

SC South Carolina

SD South Dakota

TN Tennessee

TX Texas

UT Utah

VT Vermont

VA Virginia

WA Washington

WV West Virginia

WI Wisconsin

WY Wyoming

AS American Samoa

GU Guam

MP Northern Mariana Islands

PR Puerto Rico

UM U.S. Territories: (Baker Island, Howland Island,

Jarvis Island, Johston Atoll, Kingman Reef, Midway Island, Navassa Island, Palmyra Atoll and Wake Island)

VI Virgin Islands

AA Armed Forces-Americas (excluding Canada)

AE Armed Forces-Europe, Middle East, Africa, Canada

AP Armed Forces-Pacific

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FCC Form 611-T

Approved by OMB

FCC Wireless Telecommunications Bureau 3060-1092

Annual Report Related To Eligibility See 611-T Instructions

for Designated Entity Benefits for public burden estimate

Licensee Information

1a) Purpose of Filing (Select only one): ( ) AR – DE Annual Report ( ) AM – Amendment ( ) WD – Withdrawal
1b) If this filing is for an Amendment (AM) or Withdrawal (WD), enter the File Number of the pending application currently on file with the FCC.	File Number: _________________________

FRN

2) FCC Registration Number:

Entity

3) Licensee is a(n) (Select One):

( ) Individual ( )Unincorporated Association ( )Trust ( )Government Entity ( )Corporation ( )Limited Liability Company

( ) General Partnership ( ) Limited Partnership ( ) Limited Liability Partnership

( ) Other: ___________________________________________________________________________________________________________

Licensee Name

4) Licensee Name (if entity):
5) Licensee Name (if individual):	First:	MI:	Last:	Suffix:
6) Attention To:

Address

7) P.O. Box:	And /Or	8) Street Address:
9) City:				10) State:	11) Zip Code:
12) Telephone Number: ( )			13) FAX Number: ( )
14) E-Mail Address:

15) Demographics (Optional):

Race: ( )American Indian or Alaska Native ( )Asian ( )Black or African-American ( )Native Hawaiian or Other Pacific Islander ( )White

Ethnicity: ( )Hispanic or Latino ( )Not Hispanic or Latino

Gender: ( )Male ( )Female

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Licensee Contact Information

Contact Name (if other than Licensee)

( ____ ) Check here if same as Licensee Information

16) Name:	First:	MI:	Last:	Suffix:
17) Company Name:
18) Attention To:

Address

19) P.O. Box:	And /Or	20) Street Address:
21) City:				22) State:	23) Zip Code:
24) Telephone Number: ( )			25) FAX Number: ( )
26) E-Mail Address:

Licensee Certification Statements

1) The Licensee certifies that all of its statements made in this Report and in the exhibits, attachments, or documents incorporated by reference are material, are part of this Report, and are true, complete, correct, and made in good faith.

2. The Licensee certifies that neither it nor any other party to the application is subject to a denial of Federal benefits pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988, 21 U.S.C. § 862, because of a conviction for possession of a controlled substance. See Section 1.2002(b) of the Commission’s Rules for the definition of “party to the application” as used in this certification.

2. The Licensee certifies that it is not in default on any payment for Commission licenses and that it is not delinquent on any non-tax debt owed to any federal agency.

2. The Licensee certifies that the Licensee and all of the related individuals and entities required to be disclosed on FCC Form 602 (FCC Ownership Disclosure Information for the Wireless Telecommunications Services) are not person(s) who have been, for reasons of national security, barred by any agency of the Federal Government from bidding on a contract, participating in an auction, or receiving a grant. This certification applies only to licenses for spectrum that is required by Sections 6103, 6401-6403 of the Middle Class Tax Relief and Job Creation Act of 2012, codified at 47 U.S.C. §§ 309, 1413, 1451-1452, to be assigned by a system of competitive bidding under 47 U.S.C. § 309(j).

Type or Printed Name of Party Authorized to Sign

27) First Name:	MI:	Last Name:		Suffix:
28) Title:
Signature:			29) Date:
WILLFUL FALSE STATEMENTS MADE ON THIS FORM OR ANY ATTACHMENTS 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).

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License Authorization(s) To Be Included in the Filing

30) Call Sign(s)	31) Radio Service Code	32) Initial Grant Date	33) DE Benefit Received

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