Individuals or Households

FEDERAL COMMUNICATIONS COMMISSION

REMITTANCE ADVICE
BILL FOR COLLECTION
Bill Number

Applicant FRN

Approved by OMB
3060- 0589
1 of __
1
Page __

FOR INQUIRIES CALL

Current Bill Date

1-202-418-1995
(Revenue and Receivable Operations Group)

Application Information:

Payable to:
Federal Communications Commission
Send a copy of this bill to:
Federal Communications Commission
Revenue & Receivables Operations Group
P.O. Box

Due Date

Total Amount Due

TOTAL AMOUNT DUE MUST BE RECEIVED BY
Payer FRN No.

Please Complete The Payer Information, FCC Registration Number (FRN) is required

Payer Name (if paying by credit card enter name as it appears on the card)
Address Line No. 1
Address Line No. 2
City

State

Zip Code

Daytime Phone Number (include area code)
Reason For Bill:

Call Sign/Other FCC
ID

Payment Type Code

Quantity

Fee Due For (PTC)

TOTAL DUE

Total Fee

FCC Code 1

FCC Code 2

0

Please choose a method of Payment and complete the section if paying by Credit Card

Payment Method:

CREDIT CARD

CHECK

WIRE

IPAC

MASTERCARD

DISCOVER

VISA

AMEX

ACCOUNT NUMBER__________________________________________________

MIPR

EXPIRATION DATE_____________________________________

I hereby authorize the FCC to charge my Credit Card for the service(s) / authorization(s) herein described.
AUTHORIZED SIGNATURE_________________________________________________________

DATE_____________________________________

FCC FORM 159B JULY 2005
IF PAYING BY CHECK, PLEASE WRITE YOUR BILL NUMBER ON YOUR REMITTANCE AND ATTACH A COPY OF THIS BILL TO YOUR PAYMENT TO ENSURE PROPER CREDIT.

FEDERAL COMMUNICATIONS COMMISSION

REMITTANCE ADVICE
BILL FOR COLLECTION

Approved by OMB
3060 -0589

(Continuation Sheet)
Bill Number

Applicant FRN

Current Bill Date

Call Sign/Other FCC
ID

Payment Type Code

Quantity

1 of __
1
Page __

Fee Due For (PTC)

BALANCE FORWARD

Total Fee

FCC Code 1

FCC Code 2

0
FCC FORM 159 B