FCC Form 609-T FCC Wireless Telecommunications Bureau Application to Re

FCC 609-T Approved by OMB

FEDERAL COMMUNICATIONS COMMISSION 3060-1092

Est. Avg. Burden

Per Response: 4 Hrs.

Information and Instructions

FCC Wireless Telecommunications Bureau

Application To Report Designated Entity Eligibility Event

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 4 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.

FCC 609-T – Instructions

Edition Date – Page 1

General Instructions for Application To Report Designated Entity

Reportable Eligibility Event

Purpose of Form

FCC Form 609-T is used by Designated Entities (DEs) to request prior Commission approval pursuant to Section 1.2114 of the Commission’s Rules for any reportable eligibility event. The data collected on the form is used by the FCC to determine whether the public interest would be served by the approval of the reportable eligibility event.

Who Must File and When

The Form 609-T is used by designated entities to request prior Commission approval for a reportable eligibility event as defined in Section 1.2114(a) of the Commission’s Rules and in accordance with the procedures set forth in Section 1.2114. The data collected on the form is used by the Commission to determine whether a reportable eligibility event would affect the ongoing eligibility of a designated entity for its respective designated entity benefits.

The application must be filed electronically through the Commission’s Universal Licensing System to the extent required by Section 1.913 of the Commission’s Rules.

Pursuant to Section 1.919(b)(5), any designated entity filing an application for Commission approval of a reportable eligibility event on Form 609-T must also have on file an up-to-date, accurate and complete Form 602, FCC Ownership Disclosure Information for the Wireless Telecommunications Services, at the time of filing of the FCC Form 609-T.

Required Exhibits To Be Included With Application

In addition to providing responses to the questions on this form, a number of exhibits are also required to be submitted. The following exhibits must be provided:

Exhibit A: An exhibit that lists and summarizes all agreements and arrangements (including proposed agreements and arrangements) that give rise to or otherwise relate to a reportable eligibility event. This exhibit also must include the identity of each party, including the identity of each party’s affiliates, its controlling interests, the affiliates of its controlling interests, its spectrum lessees, and its spectrum resellers and wholesalers, to each agreement or arrangement, as well as the dates on which the parties entered into each agreement or arrangement.

Exhibit B: An exhibit that discusses the potential effect of the reportable eligibility event on the designated entity benefits received by the Filer. This exhibit should include a discussion of any provisions of the agreements and arrangements listed in Exhibit A that might affect the Filer’s eligibility for designated entity benefits.

Exhibit C: Copies of each agreement and arrangement described in Exhibit A.

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.

Applicable Rules and Regulations

The Applicant 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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Edition Date – Page 2

Application Fees and Filing Locations

An application fee may be required with this form. Pursuant to Section 1.2114(c) of the Commission’s Rules, for purposes of calculating the application fee, an application on Form 609-T for consent to a reportable eligibility event will be treated as a transfer of control for purposes of determining the applicable application fee as set forth in Section 1.1102 of the Commission’s Rules. To determine the required fee amount, refer to Subpart G of Part 1 of the Commission’s Rules or the current Wireless Telecommunications Bureau Fee Filing Guide. For assistance with fees applicable to the radio services governed by the Commission’s Rules, call (877) 480-3201 (TTY (717) 338-2824). The Wireless Telecommunications Bureau Fee Filing Guide can be downloaded from the FCC's website at http://www.fcc.gov/fees, by calling the FCC's Forms Distribution Center at (800) 418-FORM (3676), or from the FCC’s Fax Information System by dialing (202) 418-0177.

Manual filings of paper applications requiring a fee must be mailed to the Federal Communications Commission, Wireless Bureau Applications, P.O. Box 358130, Pittsburgh, PA 15251‑5130, or hand delivered to the Federal Communications Commission, c/o Mellon Client Service Center, Attention FCC Module Supervisor, 500 Ross Street, Room 670, Pittsburgh, PA 15262-0001.

Manual filings of paper applications not requiring a fee must be mailed to the Federal Communications Commission, 1270 Fairfield Road, Gettysburg, PA 17325-7245, or hand delivered to the Federal Communications Commission, 1280 Fairfield Road, Gettysburg, PA 17325-7245.

Submission of Paper-Filed Forms

One original paper copy of this application is required to be filed with the Commission.

Exhibits

Each document required to be filed as an exhibit should be current as of the date of filing. Each page of every exhibit must be identified with the number or letter of the exhibit, the number of the page of the exhibit, and the total number of pages of the exhibit. If material is to be incorporated by reference, see the instruction on incorporation by reference.

Note: Some Commission Rules require the applicant to attach one or more exhibits to an application in addition to the information requested in the application form.

Incorporation by Reference

You may incorporate by reference documents, exhibits, or other lengthy showings already on file with the FCC only if the information previously filed is more than one 8 1/2” by 11” page in length, all information therein is current and accurate in all significant respects, and the reference states specifically where the previously filed information can be found (i.e., station call sign and application file number, title of proceeding, docket number and legal citations), including exhibit and page references. Items that call for numbers or that can be answered ‘Y’ or ‘N’ or with other short answers must be answered directly without reference to a previous filing.

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). Hours are from 8:00 a.m. to 7:00 p.m. Eastern Time, Monday through Friday (except Federal holidays).

Technical Assistance for Electronic Filers

For technical assistance with filing electronically, contact the Wireless Telecommunications Bureau Technical Support line at (877) 480-3201 and select option #3.

FCC 609-T - Instructions

Edition Date – Page 3

Instructions for FCC Form 609-T

Application To Report Designated Entity Eligibility Event

General Information

Application Purpose

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 1a 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).

Other Wireless Licenses

Item 2a Enter ‘Y’ if this Application is one in a series of related Applications. Otherwise, enter ‘N’.

The purpose of this item is to indicate whether this Application is part of a reportable eligibility event involving wireless licenses not listed in this application that are held by the Licensee, affiliates of the Licensee, or third parties (e.g., spectrum swaps or multi-party transactions). Where a reportable eligibility event involves multiple licenses held by a common Licensee, a single Form should be filed whenever possible. Where a reportable eligibility event involves licenses held by affiliated Licensees or third-party licensees, a separate Form must be filed for each affiliate or licensee. Enter ‘N’ if all licenses affected by the reportable eligibility event are listed on this one Form.

Parties who plan on filing multiple related Applications are strongly encouraged to contact the Wireless Telecommunications Bureau in advance of filing this Form.

Item 2b If the response to 2a is ‘Y’ and this filing is the lead Application, enter ‘Y’. Otherwise, enter ‘N’.

Item 2c If the response to 2a is ‘Y’ and the response to 2b is ‘N’, provide the File Number of the lead Application. Parties may wish to designate a lead application for reportable eligibility events that involve a series of applications. This allows parties to submit all attachments once that are common to all applications in a transaction. The parties can then attach one exhibit to the other applications associated with the transaction in order to incorporate by reference the attachments in the lead application.

Fees and Waivers

Exemption from Application Fees

Item 3 This item notifies the FCC that the Applicant is exempt from FCC application fees. If the response is ‘Y’, an exhibit demonstrating the Applicant’s eligibility for exemption from FCC application fees must be submitted with this filing. For additional information regarding an Applicant’s eligibility to be exempt from FCC application fees, see Wireless Telecommunications Bureau Fee Filing Guide or call the FCC Support Center at 888-CALLFCC, (877) 480-3201, (TTY 717-338-2824).

Waiver of Commission Rules

Item 4a If the filing includes a request for waiver of the Commission’s Rules (other than application fee waivers), enter ‘Y’ and attach an exhibit specifying the rule section(s) for which a waiver is being requested and including a justification for the requested waiver. Otherwise, enter ‘N’.

Item 4b If the response to 4a is ‘Y’, provide the number of rule sections involved (do not enter the actual rule section(s)).

Reportable Eligibility Event

Item 5a Indicate, by selecting one or more appropriate item(s), whether the reportable eligibility event that is the subject of this application is associated with the attributable material relationship rule standard in Section 1.2110(B)(3)iv)(A) of the Commission’s Rules, or the impermissible material relationship rule standard in Section 1.2110(b)(3)(iv)(B) of the Commission’s Rules, or the controlling interest rule standard in Section 1.2110(c)(2) of the Commission’s Rules, or none of the above.

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Item 5b If the Filer is claiming that, subsequent to the occurrence of the reportable eligibility event, it would be eligible for the same level of designated entity benefits as it has before the occurrence of the reportable eligibility event, enter ‘Y’. Otherwise, enter ‘N’. If the response is ‘N’, include a discussion of the effect of the reportable eligibility event on the Filer’s designated entity benefits in Exhibit B, as listed above.

Item 5c If the reportable eligibility event includes a portion of the licensed spectrum or geographic area for any the licenses included on this application, enter ‘Y’. Otherwise, enter ‘N’. If the response is ‘Y’, include an exhibit providing details regarding the portion of spectrum and/or geographic area involved.

Ownership Disclosure Information

FCC Form 602

Item 6 Enter the File Number of the FCC Form 602 that was filed in conjunction with this reportable eligibility event or already on file with the FCC and continues to be complete and accurate.

Licensee Information

Items 7 through 19 identify the Licensee.

FCC Registration Number (FRN)

Item 7 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 8 This item indicates the legal entity type of the applicant. 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 9 and 10 If Item 8 is an ‘Individual’, enter the individual name in Item 10. Otherwise, enter the name of the legal entity in Item 9. Note: The full legal name is required for these items.

Item 11 If completing Item 10 (entity name), designate an “Attention To” person for the Licensee. Note: This item is optional.

Address

Items 12-19 Complete this section as follows:

• Either a PO Box (Item 12) or a Street Address is required (Item 13). Both may be provided.

• City, State and Zip Code are required (Items 14-16).

• Telephone Number (including area code) is required (Item 17)

• FAX Number and E-Mail Address are optional (Items 18-19).

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 20 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 21-31 These items identify the contact representative for the Licensee, if different from 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 9-19, check the box located above Item 21 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 21) or the Company Name (Item 22) is required.

• If Individual Name (Item 21) is completed, then Company Name (Item 22) and Attention To (Item 23) are optional.

• If Company Name (Item 22) is completed, then either an Individual Name (Item 21) or the Attention To (Item 23) is required.

• Either a PO Box (Item 24) or a Street Address (Item 25) is required. Both may be provided.

• City, State and Zip Code are required (Items 26-28).

• Telephone Number (including area code) is required (Item 29).

• FAX Number and E-Mail Address are optional (Items 30-31).

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.

Items 32-34 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 35 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 36 In this column, list the Radio Service Code for each Call Sign listed in Item 35. The Radio Service Code is a 2-letter code and is located on FCC authorizations.

Item 37 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 38 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.

FCC 609-T – Instructions

Edition Date – Page 6

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

FCC 609-T – Instructions

Edition Date – Page 7

FCC Form 609-T

Approved by OMB

FCC Wireless Telecommunications Bureau 3060-1092

Application To Report Eligibility Event See 609-T Instructions

for public burden estimate

General Information

Application Purpose

1a) Purpose of Filing (Select only one): ( ) RE – DE Reportable Event ( ) 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: _________________________

Other Wireless Licenses

2a) Is this filing part of a series of related filings involving other wireless license(s) held by the Applicant, affiliates of the Applicant (e.g., parents, subsidiaries, or commonly-controlled entities), or third parties that are not included on this filing and for which Commission approval is required?	( ) Yes No
2b) If the answer to 2a is ‘Y’, is this filing the lead Application?	( ) Yes No
2c) If the answer to 2a is ‘Y’ and the answer to 2b is ‘N’, provide the File Number of the lead Application.	File Number: _________________________

Fees and Waivers

3) Is the applicant exempt from FCC application fees? If the answer to 3 is ‘Y’, attach an exhibit demonstrating how the applicant is exempt from FCC application fees.	( ) Yes No
4a) Does this filing include a request for waiver of the Commission’s Rules (other than a request for application fee waivers)? If the answer to 4a is ‘Y’, attach an exhibit specifying the rule section(s) for which a waiver is being requested and include a justification for the waiver request.	( ) Yes No
4b) If the answer to 4a is ‘Y’, enter the number of rule sections involved (do not enter the actual rule section(s)).	Number of Rule Sections: ____________________________

Reportable Eligibility Event

5a) Is the reportable eligibility event associated with (CHECK ALL THAT APPLY): ( ) a. The attributable material relationship rule standard in Section 1.2110(b)(3)(iv)(A) of the Commission’s Rules? ( ) b. The impermissible material relationship rule standard in Section 1.2110(b)(3)(iv)(B) of the Commission’s Rules? ( ) c. The controlling interest rule standard in Section 1.2110(c)(2) of the Commission’s Rules? ( ) d. None of the above?
5b) Is the licensee claiming that it will retain, subsequent to the occurrence of the reportable eligibility event, eligibility for the same level of designated entity benefits as it has before the occurrence of the reportable eligibility event?	( ) Yes No
5c) Does the reportable eligibility event include only a portion of the licensed spectrum or geographic area for any of the licenses included on this application?	( ) Yes No

Ownership Disclosure Information (FCC Form 602)

6) Provide the File Number of FCC Form 602 that has been filed in conjunction with this FCC Form 609 filing or that is already on file with the FCC and continues to be complete and accurate.

File Number:__________________

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Licensee Information

FRN

7) FCC Registration Number:

Entity

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

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

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

( ) Other: ___________________________________________________________________________________________________________

Licensee Name

9) Licensee Name (if entity):
10) Licensee Name (if individual):	First:	MI:	Last:	Suffix:
11) Attention To:

Address

12) P.O. Box:	And /Or	13) Street Address:
14) City:				15) State:	16) Zip Code:
17) Telephone Number: ( )			18) FAX Number: ( )
19) E-Mail Address:

20) 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

Licensee Contact Information

Contact Name (if other than Licensee)

( ____ ) Check here if same as Licensee Information

21) Name:	First:	MI:	Last:	Suffix:
22) Company Name:
23) Attention To:

Address

24) P.O. Box:	And /Or	25) Street Address:
26) City:				27) State:	28) Zip Code:
29) Telephone Number: ( )			30) FAX Number: ( )
31) E-Mail Address:

FCC 609-T

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Licensee Certification Statements

1) The Licensee certifies that the reportable eligibility event will not be effectuated until the consent of the Federal Communications Commission has been given.

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

3) 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.

4) 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.

Type or Printed Name of Party Authorized to Sign

32) First Name:	MI:	Last Name:		Suffix:
33) Title:
Signature:			34) 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

35) Call Sign(s)	36) Radio Service Code	37) Initial Grant Date	38) DE Benefit Received

FCC 609-T

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