Official Federal Forms > Federal Communications Commission (FCC)
Remittance Advice 159 - Official Federal Forms
| Remittance Advice Form. This is a national form and can be used in Federal Communications Commission (FCC) . |
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READ INSTRUCTIONS CAREFULLY Approved by OMB BEFORE PROCEEDING FEDERAL COMMUNICATIONS COMMISSION 3060-0589 REMITTANCE ADVICE Page No__ of__ (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 ADDRESS 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 CONTI NUATION 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 FCC USE ONLY (28B)FCC CODE I (29B) FCC CODE 2 SECTION D CERTIFICATION CE RTIFICATION STATEMENT I, , certify under penalty of perjury that the foregoing and supporting information is true and correc t 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 F ORM 159 FEBRUARY 2003(REVISED) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 Approved by OMB 3060-0589 FEDERAL COMMUNICATIONS COMMISSION SPECIAL USE REMITTANCE ADVICE (CONTINATION SHEET) Page No__ of__ FCC USE ONLY USE THIS SECTION ONLY FOR EACH ADDITIONAL APPLICANT SECTION BB ADDITIONAL APPLICANT INFORMATION (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 CONTI NUATION 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 FCC USE ONLY (28B)FCC CODE I (29B) FCC CODE 2 (23C) CALL SIGN/OTHER ID (24C) PAYMENT TYPE CODE (25C) QUANTITY (26C) FEE DUE FOR (PTC) (27C) TOTAL FEE FCC USE ONLY (28C) FCC CODE I (29C) FCC CODE 2 (23D) CALL SIGN/OTHER ID (24D) PAYMENT TYPE CODE (25D) QUANTITY (26D) FEE DUE FOR (PTC) (27D) TOTAL FEE FCC USE ONLY (28D)FCC CODE I (29D) FCC CODE 2 (23E) CALL SIGN/OTHER ID (24E) PAYMENT TYPE CODE (25E) QUANTITY (26E) FEE DUE FOR (PTC) (27E) TOTAL FEE FCC USE ONLY (28E) FCC CODE I (29E) FCC CODE 2 (23F) CALL SIGN/OTHER ID (24F) PAYMENT TYPE CODE (25F) QUANTITY (26F) FEE DUE FOR (PTC) (27F) TOTAL FEE FCC USE ONLY (28F)FCC CODE I (29B) FCC CODE 2 SEE PUBLIC BURDEN ON REVERSE FCC FORM 159-C FEBRUARY 2003(REVISED) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 ADVICE REFERENCE GUIDE HOW TO USE FCC FORM 159 -REMITTANCE ADVICE The FCC Form 159, "Remittance Advice, and FCC Form 159-C, (Continuation Sheet) is a multi-purpose form that must accompany any payment to the Federal Communications Commi ssion (e.g., Regulatory Fees, Processing Fees, Auctions, Fines, Forfeitures, Freedom of Informat ion Act (FOIA) Billings, or any other debt due to the FCC). The information on this form is collected t o ensure credit for full payment, to ensure you receive any refunds due, to service public inquiries, and to comply with the Debt Collection Improvement Act of 1996. Note: Fee Filing Guides can be obtained by calling Forms Distribution -- (202) 418-3676 or 1-800-418-3676, or by calling FCCs fax-on-demand -- (202) 418-0177 from the handset of a fax machine. Instructions for Completing FCC Form 159 & 159-C NOTE: All required blocks must be completed or it may result in a delay in processing or the return of your application. (1) Lockbox No. # - Enter the appropriate six - digit P.O. Box Number as found in either the FCC Fee Filing Guide for the service requested, or as specified in the Public Notice. SECTION A (2) Payer Name - Enter the name of the person or company (i.e., maker of the check) ma king the payment. If using an indiv idual name, enter the last name, first name, and middle initial. If a co mpany, enter the name used commercially. If paying by credit card, enter the name exactly as it app ears on your card. (3) Total Amount Paid - Enter the total amount of your remittance . (4) Street Address Line 1 - The street address or post office box number to which correspondence sh ould be sent. (5) Street Address Line 2 - This line may be used if further identification of the address is requi red. (6) City - The name of the city associated with the street address given in (4). (7) State - If the payer has a United States mailing address enter the appropriate two - digit state abbreviation as prescribed by the U.S. Post Office. If the payer has a mailing address o utside the United Sta tes, leave this section blank. (8) ZIP Code - 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. (9) Daytime Telephone Number - Enter the payers ten - digit daytime telephone number, including area code. For foreign telephone numbers include the appropriate country dialing a
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