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FCC 611-T

FEDERAL COMMUNICATIONS COMMISSION

Approved by OMB

3060-1092

Est. Avg. Burden

Per Response: 6 Hrs.

Information and Instructions

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 (3060-

1092). We will also accept your comments via the Internet if you send them to PRA@fcc.gov. 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 or by manually submitting FCC Form 160. FCC Form 160 is

available from the FCC’s web site at /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

August 2016 – Page 1

Fcc Form 611-T - Fcc Wireless Telecommunications Bureau Annual Report Related To Eligibility For Designated Entity Benefits