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Fcc Form 611-T - Fcc Wireless Telecommunications Bureau Annual Report Related To Eligibility For Designated Entity Benefits Page 8

Licensee Contact Information

Contact Name (if other than Licensee)

( ____ ) Check here if same as Licensee Information

16) Name:

First:

MI:

Last:

Suffix:

17) Company Name:

18) Attention To:

Address

19) P.O. Box:

And

20) Street Address:

/Or

21) City:

22) State:

23) Zip Code:

24) Telephone Number: (

)

25) FAX Number: (

)

26) E-Mail Address:

Licensee Certification Statements

1) The Licensee certifies that all of its statements made in this Report and in the exhibits, attachments, or documents incorporated by reference are

material, are part of this Report, and are true, complete, correct, and made in good faith.

The Licensee certifies that neither it nor any other party to the application is subject to a denial of Federal benefits pursuant to Section 5301 of the

Anti-Drug Abuse Act of 1988, 21 U.S.C. § 862, because of a conviction for possession of a controlled substance. See Section 1.2002(b) of the

Commission’s Rules for the definition of “party to the application” as used in this certification.

The Licensee certifies that it is not in default on any payment for Commission licenses and that it is not delinquent on any non-tax debt owed to

any federal agency.

The Licensee certifies that the Licensee and all of the related individuals and entities required to be disclosed on FCC Form 602 (FCC Ownership

Disclosure Information for the Wireless Telecommunications Services) are not person(s) who have been, for reasons of national security, barred

by any agency of the Federal Government from bidding on a contract, participating in an auction, or receiving a grant. This certification applies

only to licenses for spectrum that is required by Sections 6103, 6401-6403 of the Middle Class Tax Relief and Job Creation Act of 2012, codified

at 47 U.S.C. §§ 309, 1413, 1451-1452, to be assigned by a system of competitive bidding under 47 U.S.C. § 309(j).

Type or Printed Name of Party Authorized to Sign

27) First Name:

MI:

Last Name:

Suffix:

28) Title:

Signature:

29) Date:

WILLFUL FALSE STATEMENTS MADE ON THIS FORM OR ANY ATTACHMENTS ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S.

Code, Title 18, Section 1001) AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. Code, Title 47, Section

312(a)(1)), AND/OR FORFEITURE (U.S. Code, Title 47, Section 503).

FCC 611-T

August 2016 – Page 2

Fcc Form 611-T - Fcc Wireless Telecommunications Bureau Annual Report Related To Eligibility For Designated Entity Benefits Page 8

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