Form 159 - Remittance Advice - Federal Communications Commission
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5READ INSTRUCTIONS CAREFULLY
Approved by OMB
BEFORE PROCEEDING
FEDERAL COMMUNICATIONS COMMISSION
3060-0589
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REMITTANCE ADVICE
Page No__ of__
FORM 159
(1) LOCKBOX #
SPECIAL USE ONLY
FCC USE ONLY
SECTION A – PAYER INFORMATION
(2) PAYER NAME (if paying by credit card enter name exactly as it appears on the card)
(3) TOTAL AMOUNT PAID (U.S. Dollars and cents)
(4) STREET A DDRESS LINE NO.1
(5) STREET ADDRESS LINE NO. 2
(6) CITY
(7) STATE
(8) ZIP CODE
(9) DAYTIME TELEPHONE NUMBER (include area code)
(10) COUNTRY CODE (if not in U.S.A.)
FCC REGISTRATION NUMBER (FRN) REQUIRED
(11) PAYER (FRN)
(12) FCC USE ONLY
IF MORE THAN ONE APPLICANT, USE CONTINUATION SHEETS (FORM 159-C)
COMPLETE SECTION BELOW FOR EACH SERVICE, IF MORE BOXES ARE NEEDED, USE CONTINUATION SHEET
(13) APPLICANT NAME
(14) STREET ADDRESS LINE NO.1
(15) STREET ADDRESS LINE NO. 2
(16) CITY
(17) STATE
(18) ZIP CODE
(19) DAYTIME TELEPHONE NUMBER (include area code)
(20) COUNTRY CODE (if not in U.S.A.)
FCC REGISTRATION NUMBER (FRN) REQUIRED
(21) APPLICANT (FRN)
(22) FCC USE ONLY
COMPLETE SECTION C FOR EACH SERVICE, IF MORE BOXES ARE NEEDED, USE CONTINUATION SHEET
(23A) CALL SIGN/OTHER ID
(24A) PAYMENT TYPE CODE
(25A) QUANTITY
(26A) FEE DUE FOR (PTC)
(27A) TOTAL FEE
FCC USE ONLY
(28A) FCC CODE I
(29A) FCC CODE 2
(23B) CALL SIGN/OTHER ID
(24B) PAYMENT TYPE CODE
(25B) QUANTITY
(26B) FEE DUE FOR (PTC)
(27B) TOTAL FEE
FC C USE ONLY
(28B)FCC CODE I
(29B) FCC CODE 2
SECTION D – CERTIFICATION
CERTIFICATION STATEMENT
I,
, certify under penalty of perjury that the foregoing and supporting information is true and correct to
the best of my knowledge, information and belief.
SIGNATURE _______________________________________________________________
DATE _________________________
SECTION E - CREDIT CARD PAYMENT INFORMATION
MASTERCARD______
VISA_______
AMEX_______ DISCOVER_______
ACCOUNT NUMBER_____________________________________________________
EXPIRATION DATE ____________________________________
I hereby authorize the FCC to charge my credit card for the service(s)/authorization herein described.
SIGNATURE__________________________________________________________________________
DATE_____________________________________
SEE PUBLIC BURDEN ON REVERSE
FCC FORM 159
FEBRUARY 2003
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