FCC Form 1877 INCUMBENT 39 GHZ LICENSEE POST-AUCTION CERTIFICATIONS AN

OMB Control No. 3060-1268

FCC Form 1877 (March 2020)

_____________________________________________________________________________________________

INCUMBENT 39 GHZ LICENSEE

POST-AUCTION CERTIFICATIONS AND INSTRUCTIONS

NOTICE: We have estimated that each response to this collection of information will take 5 hours. 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 1877. 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 (3060-1268), 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 3060-1268, edition date March 2020.

Part 1: Incumbent 39 GHz Licensee Information

1.a. Name of the Incumbent 39 GHz Licensee shown on the Auction 103 Closing Public Notice.

1.b. Name of the Incumbent 39 GHz Licensee as listed in the FCC’s Commission Registration System (CORES), if different than the name entered in Part 1.a.

1.c. Enter the FCC Registration Number (FRN) of the Incumbent 39 GHz Licensee as show on the Auction 103

Closing Public Notice.

1 d. Name and contact information for the Initial Commitment Representative previously named in the FCC

Form 175-A for the Part l.a Incumbent 39 GHz License, who will serve as the contact for addressing any

questions with respect to this FCC Form 1877.

Name: First Middle Initial Last

Email Address:

Address: Street Number and Name
City State Zip Code

Telephone Number:

Part 2: Certifications

Instructions for completion of Part 2.a. The Part 2.a certifications, agreements and acknowledgements below must be signed by the Incumbent 39 GHz Licensee or, if the licensee is an entity, by an authorized corporate officer of the Incumbent 39 GHz Licensee. Each signature must be properly acknowledged and notarized.

Part 2.a. By its signature below, the Part 1.a., Incumbent 39 GHz Licensee does hereby:

1. Acknowledge and agree that the Auction 103 Closing Public Notice sets forth the correct incentive payment associated with the Incumbent 39 GHz Licensee calculated using Auction 103 procedures that provide for a single incentive payment amount for the relinquishment of all spectrum usage rights pursuant to 39 GHz licenses held by the Incumbent 39 GHz Licensee and any 39 GHz Licensee listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A, regardless of the number of licenses or licensees, applied toward any winning bids for new licenses by the Incumbent 39 GHz Licensee, and whether paid to the Incumbent 39 GHz Licensee and/or any 39 GHz Licensee(s) listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A.

2. Acknowledge and agree that this FCC Form 1877 and related submissions provide correct, accurate and complete instructions and information, including for the disbursement of the incentive payment associated with the Incumbent 39 GHz Licensee set forth in the Auction 103 Closing Public Notice.

3. Acknowledge and agree that the incentive payment associated with the Incumbent 39 GHz Licensee set forth in the Auction 103 Closing Public Notice will not be made to (or for the benefit of) any payee appearing on the U.S. Treasury’s “Do Not Pay” portal.

4. Acknowledge and agree that the incentive payment will be made from Federal funds and that any person who knowingly submits this FCC Form 1877 or related submissions containing any misrepresentation or any false, incomplete or misleading information may be subject to criminal, civil and administrative action and penalties, under applicable Federal law.

5. Certify that the Incumbent 39 GHz Licensee is in compliance with all applicable statutes, regulations, rules and instructions entitling it, or relating, to an incentive payment.

6. Acknowledge liability to the Commission for any debt owed to the Commission as of the date of this acknowledgement, including all accrued interest, penalties and costs, and that the debt will continue to accrue interest and costs until paid.

7. Acknowledge and agree that any payment of the incentive payment for the Incumbent 39 GHz Licensee may be subject to offset, and authorize the Commission to set off against cash amounts paid for the incentive payment associated with the Incumbent 39 GHz Licensee any and all debts owed to the Commission by the Incumbent 39 GHz Licensee and any 39 GHz Licensee listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A or related parties.

8. Acknowledge and agree that if an appeal of, or request for waiver, reduction or compromise of, any debt owed to the Commission by the Incumbent 39 GHz Licensee or any 39 GHz Licensee(s) listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A is pending at the conclusion of Auction 103, the Commission may withhold so much of the Incentive Payment associated with the Incumbent 39 GHz Licensee as is necessary to pay the debt in full, including accrued interest, penalties and costs, until issuance of a final non-appealable decision regarding the appeal, or waiver, reduction or compromise request, and may then pay the debt in full from the withheld portion of the Incentive Payment associated with the Incumbent 39 GHz Licensee.

9. Affirm and ratify all representations, warranties, acknowledgements, certifications, agreements and actions made or taken on behalf of the Incumbent 39 GHz Licensee by its Initial Commitment Representative(s) in connection with Auction 103.

10. Acknowledge and agree that the Incumbent 39 GHz Licensee remains subject to the Commission's jurisdiction and authority to impose enforcement or other Commission liabilities with respect to relinquished 39 GHz license(s).

11. Acknowledge that the Commission did not differentiate among separate existing 39 GHz licenses held by the Incumbent 39 GHz Licensee and any 39 GHz Licensee listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A for purposes of reconfiguring 39 GHz holdings in Auction 103.

12. Unconditionally release the United States, the Commission, and their employees, officers, agents and representatives from any and all liability or claims of the Incumbent 39 GHz Licensee individually or in a representative capacity related to or arising from Auction 103 or its or their 39 GHz license(s).

13. Indemnify and hold harmless the United States, the Commission, and their employees, officers, agents and representatives from any and all liability or claims of the Incumbent 39 GHz Licensee, any other 39 GHz Licensee listed on the Incumbent GHz Licensee’s FCC form 175-A, and the Initial Commitment Representatives, arising from or related to Auction 103.

These certifications must be executed by either the person who is the Incumbent 39 GHz Licensee or by an authorized corporate officer, if the Incumbent 39 GHz Licensee is not a person.

2.a.1 Signature:

2.a.2 Type or Print Name:

2.a.3 Type or Print “Licensee” for persons holding a license or the name of the corporation holding the license and the title of the authorized corporate officer signing this form on its behalf.

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:

Instructions for completion of Part 2.b.: The Part 2.b. certifications, acknowledgement and agreements below must be signed by each 39 GHz Licensee named on the FCC Form 175-A filed by the Incumbent 39 GHz Licensee. If the licensee is an entity rather than an individual, an authorized corporate officer must sign on the entity’s behalf. Each signature must be properly acknowledged and notarized.

Part 2.b. By having these certifications signed below, the undersigned 39 GHz Licensee listed on the FCC Form 175-A submitted by the Part 1.a. Incumbent 39 GHz Licensee does hereby:

1. Acknowledge and agree that the Incumbent 39 GHz Licensee had and continues to have full power and authority to act on behalf of the undersigned 39 GHz Licensee in all aspects of Auction 103, including but not limited to the following actions taken and/or to be taken by the Incumbent 39 GHz Licensee in Auction 103:

   1. Appointing an Initial Commitment Representative(s) to represent the Incumbent 39 GHz Licensee and each 39 GHz Licensee identified in the FCC Form 175-A submitted by the Incumbent 39 GHz Licensee;

   2. Committing each 39 GHz Licensee identified in the FCC Form 175-A submitted by the Incumbent 39 GHz Licensee to relinquish spectrum usage rights pursuant to all 39 GHz licenses held in exchange for an incentive payment;

   3. Reconfiguring spectrum usage rights held by each 39 GHz Licensee identified in the FCC Form 175-A submitted by the Incumbent 39 GHz Licensee as part of the Initial Commitment process;

   4. Making representations, certifications, and agreements on behalf of each 39 GHz Licensee identified in the FCC Form 175-A submitted by the Incumbent 39 GHz Licensee with respect to Auction 103; and

   5. Designating one or more of the Incumbent 39 GHz Licensee and the 39 GHz Licensee(s) identified in the FCC Form 175-A submitted by the Incumbent 39 GHz Licensee to receive any incentive payment with respect to the relinquished spectrum usage rights of each 39 GHz Licensee identified in the FCC Form 175-A submitted by the Incumbent 39 GHz Licensee with respect to Auction 103.

2. Acknowledge and agree that the Auction 103 Closing Public Notice sets forth the correct incentive payment associated with the Incumbent 39 GHz Licensee calculated using Auction 103 procedures that provide for a single incentive payment amount for the relinquishment of all spectrum usage rights pursuant to 39 GHz licenses held by the Incumbent 39 GHz Licensee and any 39 GHz Licensee listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A, regardless of the number of licenses or licensees, applied toward any winning bids for new licenses by the Incumbent 39 GHz Licensee, and whether paid to the Incumbent 39 GHz Licensee and/or any 39 GHz Licensee(s) listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A.

3. Certify that this FCC Form 1877 and related submissions provide correct, accurate and complete instructions and information, including for the disbursement of the incentive payment associated with the Incumbent 39 GHz Licensee set forth in the Auction 103 Closing Public Notice.

4. Acknowledge and agree that the incentive payment associated with the Incumbent 39 GHz Licensee set forth in the Auction 103 Closing Public Notice will not be made to (or for the benefit of) any payee appearing on the U.S. Treasury’s “Do Not Pay” portal.

5. Acknowledge and agree that the incentive payment will be made from Federal funds and that any person who knowingly submits this FCC Form 1877 or related submissions containing any misrepresentation or any false, incomplete or misleading information may be subject to criminal, civil and administrative action and penalties, under applicable Federal law.

6. Certify that the undersigned 39 GHz Licensee is in compliance with all applicable statutes, regulations, rules and instructions entitling it, or relating, to an incentive payment.

7. Acknowledge liability to the Commission for any debt owed to the Commission as of the date of this acknowledgement, including all accrued interest, penalties and costs, and that the debt will continue to accrue interest and costs until paid.

8. Acknowledge and agree that any payment of the incentive payment associated with the Incumbent 39 GHz Licensee may be subject to offset, and authorize the Commission to set off against cash amounts paid for the incentive payment any and all debts owed to the Commission by the Incumbent 39 GHz Licensee and any 39 GHz Licensee listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A or related parties.

9. Acknowledge and agree that if an appeal of, or request for waiver, reduction or compromise of, any debt owed to the Commission by the Incumbent 39 GHz Licensee or any 39 GHz Licensee(s) listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A is pending at the conclusion of Auction 103, the Commission may withhold so much of the Incentive associated with the Incumbent 39 GHz Licensee as is necessary to pay the debt in full, including accrued interest, penalties and costs, until issuance of a final non-appealable decision regarding the appeal, or waiver, reduction or compromise request, and may then pay the debt in full from the withheld portion of the Incentive Payment associated with the Incumbent 39 GHz Licensee.

10. Affirm and ratify all representations, warranties, acknowledgements, certifications, agreements and actions made or taken on behalf of the undersigned 39 GHz Licensee by the Initial Commitment Representative(s) named of the FCC Form 175-A filed by the Incumbent 39 GHz Licensee in connection with Auction 103.

11. Acknowledge and agree that the undersigned 39 GHz Licensee remains subject to the Commission's jurisdiction and authority to impose enforcement or other Commission liabilities with respect to relinquished 39 GHz license(s).

12. Acknowledge that the Commission did not differentiate among separate existing 39 GHz licenses held by the Incumbent 39 GHz Licensee and any 39 GHz Licensee listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A for purposes of reconfiguring 39 GHz holdings in Auction 103.

13. Unconditionally release the United States, the Commission, and their employees, officers, agents and representatives from any and all liability or claims of the undersigned 39 GHz Licensee individually or in a representative capacity related to or arising from Auction 103 or its or their 39 GHz license(s).

14. Indemnify and hold harmless the United States, the Commission, and their employees, officers, agents and representatives from any and all liability or claims of the undersigned 39 GHz Licensee, the Incumbent 39 GHz Licensee, and any other 39 GHz Licensee listed on the Incumbent GHz Licensee’s FCC form 175-A, and the Initial Commitment Representatives, arising from or related to Auction 103.

These certifications must be executed by either the person who is the 39 GHz Licensee or by an authorized corporate officer, if the 39 GHz Licensee is not a person.

2.b.1 Signature:

2.b.2 Type or Print Name:

2.b.3 Type or Print “Licensee” for persons holding a license or the name of the corporation holding the license and the title of the authorized corporate officer signing this form on its behalf.

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:

Instructions for completion of Part 2.c: The Part 2.c. certifications, acknowledgement and agreements below must be signed by each 39 GHz Licensee named on the FCC Form 175-A filed by the Incumbent 39 GHz Licensee. If the licensee is an entity rather than an individual, an authorized corporate officer must sign on the entity’s behalf. Each signature must be properly acknowledged and notarized.

Part 2.c. By having these certifications signed below, the undersigned 39 GHz Licensee listed on the FCC Form 175-A submitted by the Part 1.a. Incumbent 39 GHz Licensee does hereby:

1. Acknowledge and agree that the Incumbent 39 GHz Licensee had and continues to have full power and authority to act on behalf of the undersigned 39 GHz Licensee in all aspects of Auction 103, including but not limited to the following actions taken and/or to be taken by the Incumbent 39 GHz Licensee in Auction 103:

   1. Appointing an Initial Commitment Representative(s) to represent the Incumbent 39 GHz Licensee and each 39 GHz Licensee identified in the FCC Form 175-A submitted by the Incumbent 39 GHz Licensee;

   2. Committing each 39 GHz Licensee identified in the FCC Form 175-A submitted by the Incumbent 39 GHz Licensee to relinquish spectrum usage rights pursuant to all 39 GHz licenses held in exchange for an incentive payment;

   3. Reconfiguring spectrum usage rights held by each 39 GHz Licensee identified in the FCC Form 175-A submitted by the Incumbent 39 GHz Licensee as part of the Initial Commitment process;

   4. Making representations, certifications, and agreements on behalf of each 39 GHz Licensee identified in the FCC Form 175-A submitted by the Incumbent 39 GHz Licensee with respect to Auction 103; and

   5. Designating one or more of the Incumbent 39 GHz Licensee and the 39 GHz Licensee(s) identified in the FCC Form 175-A submitted by the Incumbent 39 GHz Licensee to receive any incentive payment with respect to the relinquished spectrum usage rights of each 39 GHz Licensee identified in the FCC Form 175-A submitted by the Incumbent 39 GHz Licensee with respect to Auction 103.

2. Acknowledge and agree that the Auction 103 Closing Public Notice sets forth the correct incentive payment associated with the Incumbent 39 GHz Licensee calculated using Auction 103 procedures that provide for a single incentive payment amount for the relinquishment of all spectrum usage rights pursuant to 39 GHz licenses held by the Incumbent 39 GHz Licensee and any 39 GHz Licensee listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A, regardless of the number of licenses or licensees, applied toward any winning bids for new licenses by the Incumbent 39 GHz Licensee, and whether paid to the Incumbent 39 GHz Licensee and/or any 39 GHz Licensee(s) listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A.

3. Certify that this FCC Form 1877 and related submissions provide correct, accurate and complete instructions and information, including for the disbursement of the incentive payment associated with the Incumbent 39 GHz Licensee set forth in the Auction 103 Closing Public Notice.

4. Acknowledge and agree that the incentive payment associated with the Incumbent 39 GHz Licensee set forth in the Auction 103 Closing Public Notice will not be made to (or for the benefit of) any payee appearing on the U.S. Treasury’s “Do Not Pay” portal.

5. Acknowledge and agree that the incentive payment will be made from Federal funds and that any person who knowingly submits this FCC Form 1877 or related submissions containing any misrepresentation or any false, incomplete or misleading information may be subject to criminal, civil and administrative action and penalties, under applicable Federal law.

6. Certify that the undersigned 39 GHz Licensee is in compliance with all applicable statutes, regulations, rules and instructions entitling it, or relating, to an incentive payment.

7. Acknowledge liability to the Commission for any debt owed to the Commission as of the date of this acknowledgement, including all accrued interest, penalties and costs, and that the debt will continue to accrue interest and costs until paid.

8. Acknowledge and agree that any payment of the incentive payment associated with the Incumbent 39 GHz Licensee may be subject to offset, and authorize the Commission to set off against cash amounts paid for the incentive payment any and all debts owed to the Commission by the Incumbent 39 GHz Licensee and any 39 GHz Licensee listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A or related parties.

9. Acknowledge and agree that if an appeal of, or request for waiver, reduction or compromise of, any debt owed to the Commission by the Incumbent 39 GHz Licensee or any 39 GHz Licensee(s) listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A is pending at the conclusion of Auction 103, the Commission may withhold so much of the Incentive associated with the Incumbent 39 GHz Licensee as is necessary to pay the debt in full, including accrued interest, penalties and costs, until issuance of a final non-appealable decision regarding the appeal, or waiver, reduction or compromise request, and may then pay the debt in full from the withheld portion of the Incentive Payment associated with the Incumbent 39 GHz Licensee.

10. Affirm and ratify all representations, warranties, acknowledgements, certifications, agreements and actions made or taken on behalf of the undersigned 39 GHz Licensee by the Initial Commitment Representative(s) named of the FCC Form 175-A filed by the Incumbent 39 GHz Licensee in connection with Auction 103.

11. Acknowledge and agree that the undersigned 39 GHz Licensee remains subject to the Commission's jurisdiction and authority to impose enforcement or other Commission liabilities with respect to relinquished 39 GHz license(s).

12. Acknowledge that the Commission did not differentiate among separate existing 39 GHz licenses held by the Incumbent 39 GHz Licensee and any 39 GHz Licensee listed on the Incumbent 39 GHz Licensee’s FCC Form 175-A for purposes of reconfiguring 39 GHz holdings in Auction 103.

13. Unconditionally release the United States, the Commission, and their employees, officers, agents and representatives from any and all liability or claims of the undersigned 39 GHz Licensee individually or in a representative capacity related to or arising from Auction 103 or its or their 39 GHz license(s).

14. Indemnify and hold harmless the United States, the Commission, and their employees, officers, agents and representatives from any and all liability or claims of the undersigned 39 GHz Licensee, the Incumbent 39 GHz Licensee, and any other 39 GHz Licensee listed on the Incumbent GHz Licensee’s FCC form 175-A, and the Initial Commitment Representatives, arising from or related to Auction 103.

These certifications must be executed by either the person who is the 39 GHz Licensee or by an authorized corporate officer, if the 39 GHz Licensee is not a person.

2.c.1 Signature:

2.c.2 Type or Print Name:

2.c.3 Type or Print “Licensee” for persons holding a license or the name of the corporation holding the license and the title of the authorized corporate officer signing this form on its behalf.

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:

Part 3: Financial Institution Information for Automated Clearing House (ACH) Payment(s)

Part 3 must be completed only if the Incentive Payment associated with the Incumbent 39 GHz Licensee exceeds any winning bids for new licenses by the Incumbent 39 GHz Licensee. If not, leave Part 3 blank.

If the Incumbent 39 GHz Licensee did NOT list any additional 39 GHz Licensees on its FCC Form 175-A, the Incumbent should complete Part 3 ONLY with respect to Recipient A. Other Incumbent 39 GHz Licensees completing Part 3 may enter its own name or the name of other 39 GHz Licensees listed on its FCC Form 175-A as Recipient A and/or additional Recipients. For each permissible recipient, enter the recipient’s name; the recipient’s FRN; taxpayer identification number (TIN); and the amount to be paid to that recipient. Provide the necessary financial institution information to pay the amount (s) using Automated Clearing House (ACH) payments.

Remember that permissible recipients of some or all of the Incentive Payment listed in the Auction 103 Closing Public Notice for the Incumbent 39 GHz Licensee are ONLY the Incumbent 39 GHz Licensee and any 39 GHz Licensee with an FRN listed in the Incumbent 39 GHz Licensee’s FCC Form 175-A as having 39 GHz licenses to be consolidated with the licenses of the Incumbent 39 GHz Licensee for purposes of Auction 103. If there is only 1 recipient then list it under Recipient A: 3.a.1 through 3.a.10. The amounts to be paid in Parts 3.a., 3.b., 3.c., must total what is in Part 3.d. This total must agree with the Incentive Payment associated with the Incumbent 39 GHz Licensee, after that Incentive Payment first is applied toward the winning bids for new licenses, if any, by the Incumbent 39 GHz Licensee, pursuant to Auction 103 procedures.

Attach to this Form 1877 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 1877), or

• A redacted bank statement that confirms ownership of the bank account.

Note: The Complete bank account number must be displayed and the bank support must be dated within six months of the signed date of this Form 1877.

If the permissible recipient (s) 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.

If a new Form 1877 needs to be filed because the financial information in Part 3 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 1877 along with attachment to support the banking.

RECIPIENT A (required):

3.a.1. Licensee Name of Permissible Recipient

3.a.2. FCC Registration Number (FRN):

3.a.3. Taxpayer Identification Number (must be 9 digits)

3.a.4. Amount to be paid to Recipient A:

3.a.5. Name of Financial Institution to send Payment to:

3.a.6. ACH Routing Transit No:

3.a.7. Name on Bank Account:

3.a.8. Account Number:

3.a.10. Is Recipient A the owner of the account in 3.a.8.? Yes or No (circle one)

If the name on the bank account is different from name listed in Part 1.b., the Recipient must either be the owner of the bank account or there must be an ownership relationship between the Recipient 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 Recipient and the owner of the bank account.

________________________________________________________________________________________________

RECIPIENT B (optional):

3.b.1. Licensee Name of Permissible Recipient

3.b.2. FCC Registration Number (FRN) (must be different from Recipients A & C):

3.b.3. Taxpayer Identification Number (must be 9 digits)

3.b.4. Amount to be paid to Recipient B:

3.b.5. Name of Financial Institution to send Payment to:

3.b.6. ACH Routing Transit No:

3.b.7. Name on Bank Account:

3.b.8. Account Number:

3.b.10. Is Recipient B the owner of the account in 3.b.8.? Yes or No (circle one)

If the name on the bank account is different from name listed in Part 1.b., the Recipient must either be the owner of the bank account or there must be an ownership relationship between the Recipient 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 Recipient and the owner of the bank account.

RECIPIENT C

RECIPIENT C (optional):

3.c.1. Licensee Name of Permissible Recipient

3.c.2. FCC Registration Number (FRN) (must be different from Recipients A & B):

3.c.3. Taxpayer Identification Number (must be 9 digits)

3.c.4. Amount to be paid to Recipient C:

3.c.5. Name of Financial Institution to send Payment to:

3.c.6. ACH Routing Transit No:

3.c.7. Name on Bank Account:

3.c.8. Account Number:

3.c.10. Is Recipient C the owner of the account in 3.c.8.? Yes or No (circle one)

If the name on the bank account is different from name listed in Part 1.b., the Recipient must either be the owner of the bank account or there must be an ownership relationship between the Recipient 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 Recipient and the owner of the bank account.

_______________________________________________________________________________________________

Please total payments to all Recipients below. If there were no payments to Recipient B and C then enter $0.00 for the respective line entries (3.d.2. and 3.d.3.).

3.d.1. Amount in Part 3.a.4 to be paid to Recipient A:

3.d.2. Amount in Part 3.b.4 to be paid to Recipient B:

3.d.3. Amount in Part 3.c.4. to be paid to Recipient C:

3.d.4. Total Amount to be paid

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