Form 161 - Cores Update And Change Form (Page 3 of 4) in pdf

(14) State (Domestic Addresses only): If the contact representative has a United States mailing address enter the

appropriate two-digit state abbreviation as prescribed by the U.S. Post Office. If the contact representative has a

mailing address outside the United States, leave this section blank.

(15) ZIP Code (Domestic Addresses only): Enter the appropriate five or nine-digit ZIP code prescribed by the U.S.

Post Office. If address is foreign, enter the appropriate ZIP (postal) code. (Domestic address only)

(16) Country (International Addresses only): If the contact representative has a mailing address outside the

United States, enter the appropriate country.

(17) Contact Representative Daytime Telephone Number (optional for individuals): Enter the contact

representative's ten-digit daytime telephone number, including area code. For foreign telephone numbers include the

appropriate country dialing access code, as if you were calling from the United States. This daytime number should

be the number where you can be reached during normal business hours.

(18) Contact Representative Fax Number (optional): Enter the contact representative's ten-digit fax number,

including area code. For foreign fax numbers include the appropriate country dialing access code, as if you were

calling from the United States.

(19) Contact Representative E-mail Address (optional): Enter the contact representative's e-mail address.

(20) Personal Security Question: Select your Personal Security Question. In the event that you forget your

CORES password, your Personal Security Question and answer will be used to verify your identity. If you are not

satisfied with any of the Personal Security Questions on the list, select Custom Personal Security Question and

provide us with your own question in 21a.

(20)(a) Custom Personal Security Question: If you selected Custom Personal Security Question in (21), provide

your own Personal Security Question here. (Maximum 100 characters, including spaces)

(21) Personal Security Question Answer: Provide the answer to the Personal Security Question you had

previously specified in (21). (Maximum 60 characters, including spaces)

(22) Certification Statement: Read the certification statement and provide your signature if you agree to the stated

claim.

Send completed forms to:

FCC

Attention: CORES Administrator

Room: 2-A629

445 12th St, SW

Washington, DC 20554

NOTICE TO INDIVIDUALS REQUIRED BY THE PRIVACY ACT OF 1974 AND THE PAPERWORK

REDUCTION ACT OF 1995

The solicitation of the personal information requested in this form is authorized by the Communications Act,

Sections 8 & 9, and the Debt Collection Improvement Act of 1996. P.L. 104-134. This form will be used

primarily to capture information to maintain required accounts receivable, and collect fines and debts due the

Commission. As part of the Debt Collection Improvement Act, agencies are authorized to refer specific

Taxpayers Identification information which includes Employers Identification Numbers and Social Security

Numbers to the Department of Treasury for further investigation and possible enforcement of a statute, rule,

regulation or order. If we believe there may be a violation or potential violation of an FCC statute, 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. If information requested on the form is

not provided, processing of the application/filing may be delayed or returned without action pursuant to

Commission rules.

Form 161 - Cores Update And Change Form Page 3

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