FCC 1068A FEDERAL COMMUNICATIONS COMMISSION Information and Instructions Approved by OMB 3060 -0132 Est. Avg. Burden Per Response: 30 Minutes SUPPLEMENTAL INFORMATION 72-76 MHz OPERATIONAL FIXED STATIONS NOTICE TO INDIVIDUALS REQUIRED BY THE PRIVACY ACT OF 1974 AND THE PAPERWORK REDUCTION ACT OF 1995 We have estimated that each response to this collection of information will take on average 30 minutes. Our estimate includes the time to read the instructions, look through existing records, gather and maintain required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Washington, DC 20554, Paperwork Reduction Project (3060-0132). 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. 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 with this notice. This collection has been assigned OMB control number 3060-0132. The FCC is authorized under the Communications Act of 1934, as amended, to collect the personal information we request in this form. We will use the information you provide to determine whether approving this application is in the public interest. If we believe there may be a violation or potential violation of a statute, FCC regulation, rule or order, your application may be referred to the 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. All parties and entities doing business with the Commission must obtain a unique identifying number called the FCC Registration Number (FRN) and supply it when doing business with the Commission. Failure to provide the FRN may delay the processing of the application. This requirement is to facilitate compliance with the Debt Collection Improvement Act of 1996 (DCIA). The FRN can be obtained electronically through the FCC webpage at http://www.fcc.gov or by manually submitting FCC Form 160. FCC Form 160 is available from the FCC’s web site at http://www.fcc.gov/formpage.html, by calling the FCC’s Forms Distribution Center 800-418-FORM (3676), or Fax Information System by dialing (202) 418-0177. 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, October 1, 1995, 44 U.S.C. 3507. FCC 1068A - Instructions March 2008 - Page 1 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR FCC 1068A NOTE: This form must be submitted along with your FCC Form 601 submission (can be submitted as an attachment if filing electronically). Item 1: Enter the location of your proposed station. All coordinates must be referenced to the North American Datum of 1983 (NAD83). This information can be determined in many ways, including a GPS receiver, a 7.5-minute topographical quadrangle map of the area, or you may consult the city or county/borough/parish surveyor in your area. Topographical maps may be purchased from the U.S. Geological Survey, Washington, DC 20242 or from its office in Denver, Colorado 80225. Enter the latitude using the format DD-MM-SS.S, where the degrees (DD) term can have a value in the range of 0 to 72, minutes (MM) can range from 0 to 59, and seconds (SS.S) can range from 0 to 59.9. If desired, seconds may be rounded to the nearest tenth of a second (in which case, use the format DD-MM-SS.S). In the right corner, specify the direction as either N for North or S for South. Enter the longitude using the format DDD-MM-SS.S, where the degrees (DDD) term can have a value in the range of 64 to 180, minutes (MM) can range from 0 to 59, and seconds (SS.S) can range from 0 to 59.9. If desired, seconds may be rounded to the nearest tenth of a second (in which case, use the format DDD-MM-SS.S). In the right corner, specify the direction as either E for East or W for West. Enter the City, Town or Village within the station’s County/Borough/Parish is nearby, and enter the County/Borough/Parish and State in which the coordinates are actually located. Refer to FCC Form 601 Main Form Instructions, Appendix II, for a list of valid state, jurisdiction, and area codes. Item 2: Enter the City and State of the location of nearest TV Channel 4 transmitter. Visit http://www.fcc.gov/mb/video/tvq.html to determine if the proposed station is within 128 km of a Channel 4 transmitter or review Appendix I for the distance. Item 3: Enter the City and State of the location of nearest TV Channel 5 transmitter. Visit http://www.fcc.gov/mb/video/tvq.html to determine if the proposed station is within 128 km of a Channel 5 transmitter or review Appendix II for the distance. Item 4: Complete if proposed station is within 128 km (80 miles) airline distance from a Channel 4 transmitter. Item 5: Complete if proposed station is within 128 km (80 miles) airline distance from a Channel 5 transmitter. Item 6: By signing this form, the applicant certifies that the statements listed in this section are true, complete, correct, and made in good faith. Item 7: This item must be completed. To be acceptable for filing, applications and amendments must be signed in accordance with Part 1 of the FCC rules. The signor must be a person authorized to sign the application. Paper originals of applications must bear an original signature. On paper originals, neither rubber-stamped nor photocopied signatures are acceptable. For filers filing electronically via ULS, the electronic signature shall consist of the name of the applicant typed on the application as a signature. Enter your ten digit FRN assigned by the Commission Registration System (CORES). The FRN is a unique entity identifier for everyone doing business with the Commission. The FRN can be obtained electronically through the FCC webpage at http://wireless.fcc.gov/uls (Select FCC Registration Number (FRN) Commission Registration System (CORES)) or by manually submitting FCC Form 160. FCC Form 160 is available for downloading from http://www.fcc.gov/formpage.html, by calling the FCC's Forms Distribution Center at (800) 418-3676, or the FCC’s Fax Information System by dialing (202) 418-0177. Note: Licensees should then associate their WTB call sign(s) electronically at http://wireless.fcc.gov/uls (Select FCC Registration Number (FRN) Commission Registration System (CORES)) or by manually submitting FCC Form 606. FCC Form 606 can also be obtained from any of the aforementioned locales as FCC Form 160. FCC 1068A - Instructions March 2008 - Page 2 American LegalNet, Inc. www.FormsWorkflow.com 90.257 APPENDIX I VerDate 0ct2002 10:08 Dec 13, 2002 Jkt 197192 PO 00000 Frm 00369 Fmt 8010 Sfmt 8006 Y:\SGML\197192T.XXX 197192T EC02AP91.008 American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com VerDate 0ct2002 10:08 Dec 13, 2002 Jkt 197192 PO 00000 Frm 00370 Fmt 8010 Sfmt 8006 Y:\SGML\197192T.XXX 197192T EC02AP91.009[43 FR 54791, Nov. 22, 1978; 44 FR 32219, June 5, 1979, as amended at 47 FR 51879, Nov. 18, 1982; 49 FR 41249, Oct. 22, 1984; 54 FR 38681, Sept. 20, 1989; 58 FR 30129, May 26, 1993; 60 FR 37268, July 19, 1995; 62 FR 18928, Apr. 17, 1997] 90.257 APPENDIX II FCC 1068A FCC WIRELESS TELECOMMUNICATIONS BUREAU SUPPLEMENTAL INFORMATION 72-76 MHz OPERATIONAL FIXED STATIONS Approved by OMB 3060 - 0132 See instructions for public burden estimate The following information and statements are required by the Rules when applying for the assignment of frequencies in the 72-76 MHz band. Refer to 47 CFR § 90.257. 1. Location of your proposed station: Latitude (DD-MM-SS.S): ( City: NAD83 ) N or S Longitude (DDD-MM-SS.S): ( County/Borough/Parish: 2. Location of nearest TV Channel 4 transmitter: City: NAD83 ) E or W State: 3. Location of nearest TV Channel 5 transmitter: State: City: State: Airline distance between Channel 4 transmitter and the proposed station: _________ km. Airline distance between Channel 5 transmitter and the proposed station: _________ km. If the distance from your proposed station to the nearest TV site in Item 2 is 128 km (80 miles) or less, complete Item 4 for Channel 4 (below). If the distance from your proposed station to the nearest TV site in Item 3 is 128 km (80 miles) or less, complete Item 5 for Channel 5 (on the reverse of this page). 4. Check (a) or check and complete (b) below for Channel 4. a. There are fewer than 100 family housing units (as defined by the U. S. Bureau of Census, see reverse), excluding units 112 or more km (70 mi.) distant from the TV antenna site, located within a circle centered at the location of the proposed fixed station. The radius shall be determined by use of the chart entitled, “Chart for Determining Radius from Fixed Station in 72-76 MHz Band to Interference Contour Along Which 10% of Service from Adjacent Channel Television Station Would be Destroyed.” (See APPENDIX I) b. There are more than 100 family housing units (as defined by the U. S. Bureau of Census, see reverse), excluding units 112 or more km (70 mi.) distant from the TV antenna site, located within a circle centered at the location of the proposed fixed station. The radius of which was determined by use of the chart listed in 4(a) above. (Use separate sheets, if necessary, for (i), (ii), and (iii).) (i) The proposed site is the only suitable location because: (ii) It is not feasible to use other available frequencies because: (iii) I will control any interference that might develop to TV reception from my operations according to the following plan: FCC 1068A March 2008 - Page 1 American LegalNet, Inc. www.FormsWorkflow.com 5. Check (a) or check and complete (b) below for Channel 5. a. There are fewer than 100 family housing units (as defined by the U. S. Bureau of Census, see below), excluding units 112 or more km (70 mi.) distant from the TV antenna site, located within a circle centered at the location of the proposed fixed station. The radius shall be determined by use of the chart entitled, “Chart for Determining Radius from Fixed Station in 72-76 MHz Band to Interference Contour Along Which 10% of Service from Adjacent Channel Television Station Would be Destroyed.” (See APPENDIX II) b. There are more than 100 family housing units (as defined by the U. S. Bureau of Census, see below), excluding units 112 or more km (70 mi.) distant from the TV antenna site, located within a circle centered at the location of the proposed fixed station. The radius of which was determined by use of the chart listed in 5(a) above. (Use separate sheets, if necessary, for (i), (ii), and (iii).) (i) The proposed site is the only suitable location because: (ii) It is not feasible to use other available frequencies because: (iii) I will control any interference that might develop to TV reception from my operations according to the following plan: “HOUSING UNIT” as defined by U. S. Bureau of Census Series AC 80-1-A or B: “Is a house, an apartment, a group of rooms, or a single room occupied as a separate living quarters or, if vacant, intended for occupancy as a separate living quarters.” 6. CERTIFICATION I certify that radiated emissions will be vertically polarized and that I am financially able and agree to make adjustments in the TV receivers affected as may be necessary to eliminate the interference caused by my operations. 7. SIGNATURE OF APPLICANT Name of Applicant (Type or Print) FCC Registration Number (FRN) Signature of Applicant Date WILLFUL FALSE STATEMENTS MADE ON THIS FORM OR ANY ATTACHMENTS ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. Code, Title 18, § 1001) AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. Code, Title 47, § 312(a) (1)), AND/OR FORFEITURE (U.S. Code, Title 47, § 503). FCC 1068A March 2008 - Page 2 American LegalNet, Inc. www.FormsWorkflow.com