FCC 5640 Ownership Change Notification

OMB 3060-1270

Secure and Trusted Communications Networks Reimbursement Program

FCC Form 5640: Ownership Change Notification

Information Submitted Using Online Portal

Estimated Time Per Response: 1 hour

(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
Filer Information
1	Filer 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 underlying Application Request for Funding Allocation filed by the Program Participant.
2	Filer Name	This is the name of the Filer submitting this request. This information will be auto-generated from the information provided in the underlying Application Request for Funding Allocation for the Program Participant.
3	Filer Information: Filer Street Name; Filer City; Filer State; Filer Zip Code; Filer Phone Number; Filer Email.	This information will be auto-generated from the information provided in the underlying Application Request for Funding Allocation submitted by the Program Participant.
Contact Information
4	Contact for Filer: 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 Filer. This is usually the headquarters offices of a large company, the law firm or other representative of the Filer, or the person or company that prepared or submitted the application on behalf of the Filer. If there is a question about the notification, an FCC representative will communicate with the Filer’s contact representative. This information will be auto-generated from the information provided in the underlying Application Request for Funding Allocation submitted by the Program Participant but filer will have the opportunity to change information to designate a different contact for the filing.
Type of Ownership Change
5	Is this a transfer of control or an assignment of assets?	Information needed to understand type of ownership change to determine whether additional actions are needed to reflect change in Reimbursement Program records.
6	Is the ownership change pro forma or non-pro forma in nature?	Information needed to understand type of ownership change to determine whether additional actions are needed to reflect change in Reimbursement Program records. A pro forma ownership change is a transfer or assignment that does not involve a substantial change in ownership or control, i.e., de facto or de jure control of the program participant remains unchanged. A non-pro forma ownership change is when the transfer or assignment does involve a substantial change in ownership or control. See Federal Communications Bar Association’s Petition for Forbearance from Section 310(d) of the Communications Act Regarding Non-Substantial Assignments of Wireless Licenses Transfers of Control Involving Telecommunications Carriers, Memorandum Opinion and Order, 13 FCC Rcd 6293, para. 7 (1998).
7	Date of Consummation	Needed to determine when the ownership change occurred.
8	If an assignment of assets, is the assignment a full or partial assignment assets?	Information needed to understand type of ownership change to determine whether additional actions are needed to reflect change in Reimbursement Program records.
9	Include an attachment describing the ownership change.	Information needed to understand type of ownership change to determine whether additional actions are needed to reflect change in Reimbursement Program records.
Program Participant’s Real Party In Interest Information
10	FCC Registration Number for Real Party In Interest prior to ownership change.	The real party in interest is the parent or other controlling entity that controls the filer. 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 underlying Application Request for Funding Allocation filed by the Program Participant.
11	Name of Real-Party-In-Interest prior to ownership change.	Legal name of the real party in interest for filer prior to ownership change. This information will be auto-generated from the information provided in the underlying Application Request for Funding Allocation filed by the Program Participant.
12	Program Participant File Number	This is the unique ID assigned to the Program Participant by the filing portal system. This information will be auto-populated.
Updated Real Party In Interest Information
13	FCC Registration Number for Real Party In Interest post ownership change consummation.	The real party in interest is the parent or other controlling entity that controls the filer. 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.
14	Name of Real-Party-In-Interest post ownership change consummation.	Legal name of the real party in interest for filer post consummation of ownership change. This information will be auto-generated from the FRN reported above.
New Program Participant’s Information
15	FCC Registration Number (FRN)	If the ownership change is an assignment of assets, then filer will need to identify the FRN for the new Program Participant. 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.
16	New Program Participant’s Name	This is the name of the new Program Participant. This information will be auto-generated from the information based on the FRN reported above.
17	New Program Participant’s Information: Street Name; City; State; Zip Code; Phone Number; Email.	This information will be auto-generated from the FRN reported above.
Contact Information for New Program Participant
18	Contact for New Program Participant: Name; Street Name; City; State; Zip Code; Phone #; Email.	These items identify the contact representative, if different from the new Program Participant. This is usually the headquarters offices of a large company, the law firm or other representative of the new Program Participant. If there is a question about the notification, an FCC representative will communicate with the new Program Participant’s contact representative. This information will be auto-generated from the information associated with the FRN identified for the new Program Participant but filer will have the opportunity to change information to designate a different contact.
Payment Information for New Program Participant
19	Commercial and Government Entity (CAGE) Code	If the ownership change is an assignment of assets, then the filer will need to provide information for the proper routing of payments from the Reimbursement Program to the new Program Participant. The CAGE code is a five-character identifier, which is used by entities doing business with the Federal government to provide banking and other related information. The System Award Management (SAM) is a government-wide portal that consolidates the capabilities of multiple systems and information sources used by the Federal government in conducting the acquisition and financial assistance (which includes grants and cooperative agreements) processes, https://www.sam.gov/SAM/. The CAGE Code is also referred to as a SAM registration number.
20	Data Universal Numbering System (DUNS) Number	A Data Universal Numbering System (DUNS) Number is a unique nine-digit number assigned by Dun & Bradstreet that is used to identify organizations, https://www.dnb.com/duns-number.html.  Filer will need to provide the DUNS number associated with the SAM CAGE code identified above.
21	DUNS+4	A DUNS+4 is the DUNS number plus a 4-character suffix. It is created by the SAM registrant to establish additional Electronic Funds Transfer (EFT) accounts for a given DUNS number registration. (DUNS+4 has no affiliation with Dun & Bradstreet), SAM Non-Federal User Guide, https://sam.gov/SAM/SAM_Guide/SAM_Non_Federal_User_Guide/ SAM_Non_Fed_User_Guide.html.
New Program Participant Type
22	Identify the primary U.S. state, District of Columbia, or U.S. territory in which reimbursement support will be applied.	If the ownership change is an assignment of assets, then the filer will need to provide information on the type of new Program Participant. This field indicates the U.S. State, District of Columbia, or U.S. territory in which the new Program Participant will primarily utilize funding received from the Reimbursement Program. This information is used to assist the FCC in reporting funding information to Congress as required by applicable statutes.
23	Identify your type of entity. Select up to 3. A - State Government; B - County Government; C - City or Township Government; D - Special District Government; E - Regional Organization; F - U.S. Territory or Possession; G - Independent School District; H - Public/State Controlled Institution of Higher Education; I - Indian/Native American Tribal Government (Federally -Recognized); J - Indian/Native American Tribal Government (Other than Federally-Recognized); K - Indian/Native American Tribal Designated Organization; L - Public/Indian Housing Authority; M - Nonprofit with section 501(c)(3) IRS Status (Other than an Institution of Higher Education); N - Nonprofit without section 501(c)(3) IRS Status (Other than an Institution of Higher Education); O - Private Institution of Higher Education; P – Individual; Q - For-Profit Organization (Other than Small Business); R - Small Business; S - Hispanic-serving Institution; T - Historically Black College or University (HBCU); U - Tribally Controlled College or University (TCCU); V - Alaska Native and Native Hawaiian Serving Institutions; W - Non-domestic (non-U.S.) Entity; X – Other.	This information is used to assist the FCC in reporting funding allocation information to Congress as required by applicable statutes. If Applicant selects “Other,” filer will be able to utilize an information field to elaborate on the new Program Participant’s description that was not adequately captured by the listed options.
24	Is the new Program Participant a commercial broadband provider?	Information will help the FCC identify applicant type and track and analyze funding allocations.
25	Is the new Program Participant an Eligible Telecommunications Carrier (ETC)?	Eligible telecommunications carriers (ETCs) as defined in 47 CFR § 54.201 receiving universal service fund support. Information will help the FCC identify applicant type and track and analyze funding allocations.
26	If new Program Participant is an ETC, then identify ETC Status (ILEC or Non-ILEC) for new Program Participant.	Information used to identify if the filer as an ETC. ILEC refers to the term Incumbent Local Exchange Carrier.
27	If new Program Participant is an ETC, please enter a list of Service Provider Identification Numbers (SPINs) that the new Program Participant uses to conduct transactions with the Universal Service Administrative Company (USAC).	A Service Provider Identification Number (SPIN) (also known as a 498 ID) is a unique nine-digit number assigned to service providers that conduct business with the Universal Service Administrative Company (USAC). A SPIN is assigned when an FCC Form 498 is filed with USAC.
28	If new Program Participant is an ETC, then identify the Study Area Code(s), where the new Program Participant is designated as an ETC.	Information used to identify geographic areas where filer is designated as an ETC.
29	New Program Participant’s FCC Form 499 Filer ID Number(s) (if applicable).	An FCC Form 499 Filer ID Number is a 6-digit identifier assigned to telecommunications providers that report quarterly and annual revenue to the FCC. This information is used to cross-check filer information with other FCC records.
30	Is new Program Participant subject to the Commission’s Part 32 - Uniform System of Accounts for Telecommunications Companies regulations, 47 CFR §§ 32.01 et seq.? (Yes or No)	Question aimed at identifying Applicants that may raise duplicate recovery concerns. The Commission’s Part 32 – Uniform System of Accounts for Telecommunications Companies applies to “every incumbent local exchange carrier, as defined in section 251(h) of the Communications Act, and any other carrier that the Commission designates by order. This part refers to such carriers as ‘companies’ or ‘Class B companies.’ Incumbent local exchange carriers’ successor or assign companies, as defined in section 251(h)(1)(B)(ii) of the Communications Act, that are found to be non-dominant by the Commission, will not be subject to this Uniform System of Accounts.” 47 CFR § 32.11.
Program Eligibility Post Consummation
31	Is the Program Participant post consummation of the ownership change a health care provider? (Yes or No)	Information will help the FCC identify Program Participant type and track and analyze funding allocations.
32	Is the Program Participant post consummation of the ownership change a school? (Yes or No)	Information will help the FCC identify Program Participant type and track and analyze funding allocations.
33	Is the Program Participant post consummation of the ownership change a library? (Yes or No)	Information will help the FCC identify the Program Paticiopant type and track and analyze funding allocations.
34	Is Program Participant post consummation of the ownership change a provider of advanced communications service with 10 million or fewer customers? (Yes or No)	The term “advanced communications service” means high-speed, switched, broadband telecommunications capability that enables users to originate and receive high-quality voice, data, graphics, and video telecommunications using any technology with connection speeds of at least 200 kbps in either direction.” 47 CFR § 1.50001(a). For additional information on the meaning of a provider of advanced communications please refer to the Second Report and Order, WC Docket No. 18-89, 35 FCC Rcd 14284, paras. 110-116 (2020). “Customers” is interpreted to include customers of the Applicant and customers of any affiliate taking advanced communications service from the provider and its affiliates as of the date the application is filed. Id. at paras. 114-115.
35	Is Program Participant post consummation of the ownership change a provider of advanced communications service with 2 million or fewer customers? (Yes or No)	“Customers” includes customers of the Applicant and customers of any affiliate taking advanced communications service from the provider and its affiliates as of the date the application is filed. Second Report and Order, WC Docket No. 18-89, 35 FCC Rcd 14284, paras. 114-115.
36	Has the Program Participant post consummation of the ownership previously purchased, leased, or otherwise obtained communications equipment or services on the Covered List that was produced or provided by Huawei Technologies Company or ZTE Corporation, including their affiliates and subsidiaries, on or before June 30, 2020? (Yes or No)	Information needed to determine whether Program Participant post consummation of ownership change remains eligible to participate in the Reimbursement Program. By statute, program is limited to the permanent removal, replacement, and disposal of certain communications equipment or service deemed “covered” and that was obtained by the eligible provider of advanced communications service by a certain date. Consistent with amendments to the Secure Networks Act by the Consolidated Appropriations Act, 2021, the Commission limited reimbursement eligibility to covered communications equipment or services produced or provided by Huawei Technologies Company or ZTE Corporation that was obtained on or before June 30, 2020.
Certifications
37	By checking the box and providing the electronic signature where indicated below, the Certifying Official on behalf of the filer and the new Program Participant (when applicable) certifies under penalty of perjury that: The Certifying Official is authorized to submit this notification on behalf of the above-named filer 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 notification has been examined and is true, accurate, and complete. The Certifying Official acknowledges that any false, fictitious, or fraudulent information or statement, or the omission of any material fact on this or on any other documents submitted by the 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 filer and new Program Participant (where applicable) will comply 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 failure to comply with the statute, rules, and orders governing the Reimbursement Program could result in civil or criminal prosecution by law enforcement authorities. The filer and the new Program Participant (where applicable) (1) will not purchase, rent, lease or otherwise obtain covered communications equipment or service published by the Commission under 47 U.S.C. § 1601(a), using reimbursement funds (including funds derived from private sources) and (2) in developing and tailoring risk management practices, will consult and consider the standards, guidelines, and best practices set forth in the cybersecurity framework developed by the National Institute of Standards and Technology. The cost estimates claimed by filer and the new Program Participant (where applicable) are eligible for reimbursement were made in good faith and are limited to only the portion of the costs that will be reasonably incurred for the removal, replacement, and disposal of covered equipment and services in accordance with the Secure and Trusted Communications Networks Act of 2019, as amended, Pub. L. 116-124 § 4 (47 U.S.C. § 1603) and the Commission’s rules (47 CFR § 1.50004). The filer and the new Program Participant (where applicable) will use all money received from the Reimbursement Program only for expenses eligible for reimbursement in accordance with the Reimbursement Program rules, orders, and statute (47 U.S.C § 1603). The filer and the new Program Participant (where applicable) will file all required documentation for its expenses. The filer and the new Program Participant (where applicable) will not use Reimbursement Program funds for any portion of expenses that have been or will be reimbursed by other sources of funding (e.g., Federal pandemic relief funding such as the Coronavirus Aid, Relief, and Economic Security (CARES) Act, Emergency Broadband Benefit Program, or other provisions of the American Rescue Plan; targeted state funding; other external sources of targeted funding; or other universal service support mechanisms). The filer and the new Program Participant (where applicable) will maintain detailed records, including receipts, of all costs claimed as eligible for reimbursement for a period of ten years. The filer and the new Program Participant (where applicable) recognizes that it may be subject to an audit, inspection or investigation pursuant to its request for funding allocation, that it will retain for ten years any and all records related to its participation in the program as required by 47 CFR § 1.50004(n), and will make such records and equipment purchased with Reimbursement Program reimbursement available at the request of any representative (including any auditor) appointed by the Commission and its Office of Inspector General, or any local, state, or Federal agency with jurisdiction over the entity. No kickbacks, as defined in 41 U.S.C. § 8701 and/or 42 U.S.C. § 1320a-7b, were paid or received by the filer and the new Program Participant (where applicable) to anyone in connection with the Reimbursement Program.	Certifications necessary to protect Reimbursement Program against waste, fraud, and abuse.
38	Certifying Official Name	Name of certifying official.
39	Certifying Official Title	Job title of certifying official.
40	Certifying Official Phone Number	Phone number of the certifying official.
41	Certifying Official Email Address	Email address of the certifying official.
42	Certifying Date Signed	The date on which the filing is certified will be auto-generated.

FCC Form 5640