FCC Form 5640 Individual Term Extension Request, Section 1.50004(h)(2)

OMB 3060-1270

[Month 2021]

Secure and Trusted Communications Networks Reimbursement Program

FCC Form 5640: Individual Term Extension Request, Section 1.50004(h)(2)

Information Submitted Using Online Portal

Estimated Time Per Response: 4 hours

(Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual representation of what each applicant will see, the order in which they will see information, or the exact wording or directions used to collect the information.)

Item Number	Field(s) Description	Purpose/Instructions
Applicant Information
1	Applicant FCC Registration Number (FRN)	An FRN is a 10-digit number that is assigned by the Commission Registration System (CORES) to a business or individual registering with the FCC. This unique FRN is used to identify the registrant’s business dealings with the FCC. This information will be auto-generated from the information provided in the Application Request for Funding Allocation.
2	Applicant Name	This is the name of the Applicant submitting this request. This information will be auto-generated from the information provided in the Application Request for Funding Allocation.
3	Applicant Information: Applicant Street Name; Applicant City; Applicant State; Applicant Zip Code; Applicant Phone Number; Applicant Email.	This information will be auto-generated from the information provided in the Application Request for Funding Allocation.
Contact Information
4	Contact different than Applicant: Contact Name; Contact Street Name; Contact City; Contact State; Contact Zip Code; Contact Phone #; Contact Email.	These items identify the contact representative, if different from the Applicant. This is usually the headquarters offices of a large company, the law firm or other representative of the Applicant, or the person or company that prepared or submitted the application on behalf of the Applicant. If there is a question about the application, an FCC representative will communicate with the Applicant’s contact representative. This information will be auto-generated from the information provided in the Application Request for Funding Allocation but filer will have the opportunity to change information to designate a different contact for the filing.
5	Contact same as Applicant: Contact Name; Contact Street Name; Contact City; Contact State; Contact Zip Code; Contact Phone #; Contact Email.	These items identify the contact representative. This is usually the headquarters offices of a large company, the law firm or other representative of the Applicant, or the person or company that prepared or submitted the application on behalf of the Applicant. If there is a question about the application, an FCC representative will communicate with the Applicant’s contact representative. This information will be auto-generated from the information provided in the Application Request for Funding Allocation but filer will have the opportunity to change information to designate a different contact for the filing.
Expiration of Term
6	Date which removal, replacement, and disposal term is set to expire.	The Commission’s rules require recipients filing petitions seeking a term extension to file the petition prior to expiration of the removal, replacement, and disposal term. This item will help the Commission verify this requirement is met. May be auto-generated by system based on other information submitted.
7	Provide justification along with any supporting documentation to support Filer's request for an extension of the removal, replacement, and disposal term.	By statute and the Commission’s rules, recipients are allowed to file petitions requesting an extension of the one-year removal, replacement, and disposal term. The Wireline Competition Bureau may grant an extension for up to six months after finding that due no fault of the recipient, the recipient is unable to complete the permanent removal, replacement, and disposal by the end of the term.
8	Indicate requested date for extension not to exceed six months.	Information needed to evaluate request, and if granted, to extend the term date.
Certifications
9	Filer certifies under penalty of perjury that all information provided in this filing is true and correct to the best of Filer’s knowledge.	Certification necessary to ensure accuracy of information provided.
10	Certifying Official Name	Name of certifying official.
11	Certifying Official Title	Job title of certifying official.
12	Certifying Official Phone Number	Phone number of the certifying official.
13	Certifying Official Email Address	Email address of the certifying official.
14	Certifying Date Signed	The date on which the filing is certified will be auto-generated.

FCC Form 5640/ [Month 2021]