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

OMB 3060-1270

September 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	By checking the box and providing the electronic signature where indicated below, the Certifying Official on behalf of the Applicant certifies under penalty of perjury that: The Certifying Official is authorized to submit this extension request on behalf of the above-named Applicant and, based on information known to me or provided to me by employees responsible for the information being submitted, the information set forth in this extension request has been examined and is true, accurate, and complete, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. The Certifying Official acknowledges that any false, fictitious, or fraudulent information or statement, or the omission of any material fact on this extension request or on other documents submitted by filer may subject the filer and the undersigned to punishment by fine or forfeiture under the Communications Act (47 U.S.C. §§ 502, 503(b), 1606), or fine or imprisonment under Title 18 of the United States Code (18 U.S.C. § 1001, §§ 286-287, and § 1343), or can lead to liability under the False Claims Act (31 U.S.C. §§ 3729-3733, and §§ 3801-3812). The Applicant is in compliance with the statute, rules, and orders governing the Reimbursement Program, including but not limited to allocations, draw downs, payments, obligations and expenditures of money, and the Certifying Official acknowledges that failure to be in compliance and remain in compliance with those statutes, rules, and orders may result in the denial of funding, cancellation of funding commitments, and/or recoupment of past disbursements. The Certifying Official acknowledges that the Applicant will maintain detailed records, including receipts, of all costs eligible for reimbursement actually incurred for a period of 10 years; and will file all required documentation for its expenses. The Certifying Official acknowledges that failure to comply with the statute, rules, and orders governing the Reimbursement Program could result in civil or criminal prosecution by law enforcement authorities.	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/ September 2021