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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 (Select FCC Registration

Number (FRN) Commission Registration System (CORES)) or by manually submitting FCC Form 160. FCC Form 160 is available for

downloading from , 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 Licensee. 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 Licensee 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

August 2016 – Page 4

Fcc Form 611-T - Fcc Wireless Telecommunications Bureau Annual Report Related To Eligibility For Designated Entity Benefits Page 4