FCC FINAL OFFER ARBITRATION Demand for Arbitration Applicable FCC Order - Please check one: ___ FCC 06-105 "Adelphia" Order ___ FCC 08-66 "Liberty" Order ___ FCC 11-4 (Please note whether dispute arises under __ Section II or __ Section IV.A) ___ Other (Please include applicable FCC Order Number _________________) Name of Claimant _______________________ Name of Representative ___________________ Name of Firm (if applicable) _______________ ___ Small MVPD ___ MVPD ___ Qualified OVD ___ Bargaining Agent ___ Other (Please describe) _____________________________________________________ Address ____________________________________ Address ____________________________ City ___________ State ____ Zip Code _______ City __________ State _____ Zip Code ______ Phone No. _____________ Fax No. _____________ Phone No. _____________ Fax No. _____________ Email Address _________________________ Email Address ____________________________ Nature of the Dispute: ___ Expired Contract ___ First Time Request ___ Other (Please describe) ________________________________________________________________________ Non-Monetary Claim AAA Administrative Filing Fee Enclosed $_________________ (In accordance with the Standard Fee Schedule of the Commercial Arbitration Rules) Hearing Locale ___________________ As Required by the Applicable FCC Order Final Offer Attached to this Demand: ___ Yes ___ No (Your Final Offer shall not be disclosed to Respondent until after receipt of Respondent's Final Offer by AAA.) AAA will provide written notice to you and the Respondent of your formal filing of a demand for arbitration and the requirement that Respondent submit their final offer to AAA by the deadline established in the applicable FCC order. Name of Respondent __________________ Type of Business ____________________ Address ___________________________ City __________ State ____ Zip Code _______ Phone No. ____________ Fax No. ____________ Name of Representative (if known) _________________ Name of Firm (if applicable)________________________ Address ________________________________ City __________ State ___ Zip Code ______ Phone No. _______________ Fax No. ____________ American LegalNet, Inc. www.FormsWorkFlow.com FCC FINAL OFFER ARBITRATION Demand for Arbitration (Page 2) Email Address _________________________ Email Address ___________________________ To begin proceedings, please sign below and send the original of this Demand and your final offer along with the filing fee for a non-monetary claim as provided for in the Standard Fee Schedule of the Commercial Arbitration Rules to: American Arbitration Association, Case Filing Services, 1101 Laurel Oak Road, Suite 100, Voorhees, NJ 08043. Signature (may be signed by a representative) _____________________ Date: ______________ Please visit our website at www.adr.org to obtain a copy of the FCC Order or contact Jean Baker at 202-223-7093. American LegalNet, Inc. www.FormsWorkFlow.com