Fillable Form 159 - Remittance Advice - Federal Communications Commission (Page 5 of 5) in pdf

SECTION D

Certification Statement

(30)

- This section must be completed and signed. Failure to do so may delay the processing

of your application/filing.

SECTION E

Credit Card Payment Information

(31)

- If remitting payment by credit card, place an "x" in the appropriate block

for the credit card bein g used – MasterCard, Visa, AMEX, or Discover. Enter your credit card number and

expiration date (For example: (mm/yyyy)). Sign and date the FCC Form 159 to authorize your credit card payment.

(If any area required for credit card approval is incomplete, the application will be returned unprocessed.)

Form 159-C FCC Remittance Advice Continuation Sheet

Use this form for any additional services pertaining to this filing or if you are paying for multiple applicants

with a single payment. (See Sections B and C of the instructions to assist you in completing this form). For each

additional applicant listed in Section BB of the FCC Form 159-C, you must complete Section BB - Block 21: FCC

Registration Number. Each additional applicant must use a separate Form 159 -C.

Note: Checks must be denominated in U.S. Currency and deposited in an U.S. financial institution. No checks

drawn on a foreign bank will be accepted.

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

OF 1995

The solicitation of the personal in formation 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 c ollect 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 a FCC statute, regulation, rule or order,

your application may be referred to t he 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.

If you owe a past due debt to the Federal Government, the Taxpayer Identification Number (such as your Social

Security Number) and other information you provide may also be disclosed to the Department of the Treasury,

Financial Management Service, other federal agencies and/or your employer to offset your salary, IRS tax refund

or other payments to collect that debt. The FCC may also provide this information to these agencies through the

matching of computer records when authorized.

We have estimated that each response to this collection of information will take 10 minutes to 4 hours. Our

estimate includes the time to read the instructions, look through existing records, gather and maintain required

data, and actually review and complete the form. If you have any comments on this estimate, or on how we can

improve the collection of this data to reduce the burden it causes you, please write the Federal Communicati on

Commission, AMD-PERM, Washington, DC 20554, Paperwork Reduction Project (3060 -0589). 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.

Remember -- 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 or if we fail to provide you with this notice. This collection has been assigned an OMB control number of

3060-0589.

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, Oct ober 1, 1995, 44 U.S.C. 3507.

Form 159 - Remittance Advice - Federal Communications Commission Page 5

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