Free 611-T - Federal

FCC 611-T

FEDERAL COMMUNICATIONS COMMISSION Information and Instructions

Approved by OMB 3060-1092 Est. Avg. Burden Per Response: 6 Hrs.

FCC Wireless Telecommunications Bureau Annual Report Related to Eligibility for Designated Entity Benefits 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 6 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 (30601092). 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 611-T ­ Instructions January 2007 ­ Page 1

General Instructions for Wireless Telecommunications Bureau Annual Report Related To Eligibility for Designated Entity Benefits
Purpose of Form FCC Form 611-T is used by designated entity licensees to file an annual report, pursuant to section 1.2110(n) of the Commission's Rules, related to eligibility for designated entity benefits. Who Must File and What Must be Filed Each designated entity licensee must file with the Commission an annual report no later than, and up to five business days before, the anniversary of each of the designated entity's license grant date(s). Licensees may file one report for all designated entity licenses in the same service that were granted on the same day. Annual Report The annual report, which should be filed as an attachment to this Form 611-T, shall include: · A list and summary of all agreements and arrangements (including proposed agreements and arrangements) that relate to eligibility for designated entity benefits for each designated entity license covered by the annual report. Similar types of agreements and arrangements should be listed together in clearly identified categories, such as, but not limited to, categories covering credit and loan, management, leasing, equipment, tower and facilties agreements and arrangements. This list and summary must include: · The parties (including affiliates, controlling interests, and affiliates of controlling interests) to each agreement or arrangement, as well as the dates on which the parties entered into each agreement or arrangement. · The dates on which any agreement or arrangement will terminate. · An indication of which agreements or arrangements are new or have been modified since the designated entity's previous Annual Report filing. · A disclosure and discussion of the specific provisions of any agreement or arrangement that could affect the licensee's eligibility for designated entity benefits. · An explanation of which licenses, if the annual report covers more than one license, are affected by each agreement or arrangement. Information regarding the designated entity's progress in meeting the applicable construction requirements for the license(s). Information regarding the services provided or planned to be provided using the license(s). Information regarding the number of subscribers served in the license(s) area. If applicable, any other information that might affect the licensee's designated entity status.

· · · ·

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. The requirement to update the annual report will be in effect until the report is changed to "received" status in the Commission's Universal Licensing System (ULS). 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.

FCC 611-T ­ Instructions January 2007 ­ Page 2

Application Fees and Filing Locations No application fee is required with this form. 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). Technical Assistance for Electronic Filers For technical assistance with filing electronically, contact the Wireless Telecommunications Bureau Technical Support line at (877) 4803201 and select option #3.

FCC 611-T - Instructions January 2007 ­ Page 3

Instructions for FCC Form 611-T Annual Report Related To Eligibility for Designated Entity Benefits Purpose of Filing
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 1b 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).

Licensee Information
Items 2 through 14 identify the Licensee. FCC Registration Number (FRN) Item 2 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 3 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 4 and 5 If Item 3 indicates the applicant is an `Individual' enter the individual name in Item 5. Otherwise, enter the name of the legal entity in Item 4. Note: The full legal name is required for these items. Item 6 If completing Item 4 (entity name), enter the contact person for the Licensee. Note: This item is optional. Address Items 7-14 Complete this section as follows: · Either a PO Box (Item 7) or a Street Address (Item 8) is required. Both may be provided. · City, State and Zip Code are required (Items 9-11). · Telephone Number (including area code) is required (Item 12). · FAX Number and E-Mail Address are optional (Items 13-14). 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 15 The information is optional and is requested for informational purposes only. Responses to this item will in no way affect processing of Applications/Notifications.

FCC 611-T ­ Instructions January 2007 ­ Page 4

Licensee Contact Information
Contact Name & Address (If other than Licensee) Items 16-26 These items identify the contact representative for 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 1-14, check the box located above Item 16 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 16) or the Company Name (Item 17) is required. · If Individual Name (Item 16) is completed, then Company Name (Item 17) and Attention To (Item 18) are optional. · If Company Name (Item 17) is completed, then either an Individual Name (Item 16) or Attention To (Item 18) is required. · Either a PO Box (Item 19) or a Street Address (Item 20) is required. Both may be provided. · City, State and Zip Code are required (Items 21-23). · Telephone Number (including area code) is required (Item 24). · FAX Number and E-Mail Address are optional (Items 25-26).

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 27-29 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 30 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 31 In this column, list the Radio Service Code for each Call Sign listed in Item 30. The Radio Service Code is a 2-letter code and is located on FCC authorizations. Item 32 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 33 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 611-T ­ Instructions January 2007 ­ Page 5

Appendix I STATE TABLE
Abbreviations for States, Jurisdictions, and Areas
AL AK AZ AR CA CO CT DE DC FL GA GM HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Gulf of Mexico Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS GU MP PR UM North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Northern Mariana Islands Puerto Rico U.S. Territories: (Baker Island, Howland Island, Jarvis Island, Johston Atoll, Kingman Reef, Midway Island, Navassa Island, Palmyra Atoll and Wake Island) Virgin Islands Armed Forces-Americas (excluding Canada) Armed Forces-Europe, Middle East, Africa, Canada Armed Forces-Pacific

VI AA AE AP

FCC 611-T ­ Instructions January 2007 ­ Page 6

FCC Form 611-T
Approved by OMB

FCC Wireless Telecommunications Bureau Annual Report Related To Eligibility for Designated Entity Benefits Licensee Information
1a) Purpose of Filing (Select only one): ( ) AR ­ DE Annual Report ( ) AM ­ Amendment (

3060-1092 See 611-T Instructions for public burden estimate

) 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: _________________________

FRN
2) FCC Registration Number:

Entity
3) Licensee is a(n) (Select One): ( ) Individual ( )Unincorporated Association ( ( ) General Partnership ( ( )Trust ( ( )Government Entity ( ( )Corporation ( ) Consortium )Limited Liability Company

) Limited Partnership

) Limited Liability Partnership

) Other: ___________________________________________________________________________________________________________

Licensee Name
4) Licensee Name (if entity): 5) Licensee Name (if individual): 6) Attention To: First: MI: Last: Suffix:

Address
7) P.O. Box: 9) City: 12) Telephone Number: ( 14) E-Mail Address: ) And /Or 8) Street Address: 10) State: 13) FAX Number: ( ) 11) Zip Code:

15) 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

FCC 611-T January 2007 ­ Page 1

Licensee Contact Information
Contact Name (if other than Licensee) ( ____ ) Check here if same as Licensee Information
16) Name: 17) Company Name: 18) Attention To: First: MI: Last: Suffix:

Address
19) P.O. Box: 21) City: 24) Telephone Number: ( 26) E-Mail Address: ) And /Or 20) Street Address: 22) State: 25) FAX Number: ( ) 23) Zip Code:

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

2)

3)

Type or Printed Name of Party Authorized to Sign
27) First Name: 28) Title: Signature: 29) Date: MI: Last Name: Suffix:

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).

FCC 611-T January 2007 ­ Page 2

License Authorization(s) To Be Included in the Filing
30) Call Sign(s) 31) Radio Service Code 32) Initial Grant Date 33) DE Benefit Received

FCC 611-T January 2007 ­ Page 3