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Statement Of Account For Secondary Transmissions By Cable Systems (Long Form) (Periods Beginning January 1 2010) Form. This is a Official Federal Forms form and can be use in US Copyright Office.
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OFFICIAL BUSINESS
UNITED STATES COPYRIGHT OFFICE
STATEMENT OF ACCOUNT
SA3 (LONG FORM)
Penalty for Private Use $300
Forwarding Service Requested
Official Business
Library of Congress
Copyright Office
Licensing Division
101 Independence Avenue SE
Washington, DC 20557-6400
SPECIAL NOTICE ABOUT THIS STATEMENT OF ACCOUNT
IMPORTANT
Multicast versus Simulcast
Multicast is a digital stream of programming that is transmitted by a television broadcast station and is not the station’s
primary stream. Simulcast is a multicast stream of a television broadcast station that duplicates the programming
transmitted by the primary stream or another multicast stream of such station.
Photocopy Required
A legible copy of the semiannual statement of account must be submitted together with the original statement of
account to the Copyright Office.
Electronic Payment of Royalty Fees Required
Detailed instructions for making royalty payments via electronic funds transfer (EFT) are contained in circulars 74a,
74b, and 74c, which are available at www.copyright.gov/circs/circ74 or by contacting the Licensing Division (8:30 am
and 5:00 pm EST) by phone at (202) 707-8150, fax (202) 707-0905, or email licfiscal@loc.gov. The remittance must be
made payable to Register of Copyrights.
Remittance Advice Information
Federal regulations (C.F.R. Title 37 201.17 [i]) require that a remittance advice be attached to the statement(s) of
account, and a copy of the remittance advice be emailed or sent by facsimile to the Licensing Division. The Office uses
this remittance information to ensure the funds received via EFT are correctly allocated to each statement of account.
Filing an accurate advice (1) facilitates processing of your payments, (2) minimizes our contact or correspondence with
you, and (3) reduces administrative and other costs.
Convenient form at http://www.copyright.gov/licensing/remittance-advice.pdf.
Library of Congress
Copyright Office
Licensing Division
101 Independence Avenue SE
Washington, DC 20557-6400
Tel: (202) 707-8150 (8:30 a.m.–5:00 p.m., EST) Fax: (202) 707-0905
Email: licensing@loc.gov or Web: www.copyright.gov/licensing
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sl-xx rev: 03 ⁄ 2010 print: 03 ⁄ 2010 – xx,000 Printed on recycled paper
U. S. Government Printing Office: 2010-357-993 ⁄ 80,069
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This form is effective for accounting periods beginning July 1, 2010
If you are filing for a prior accounting period, contact the Licensing Division for the correct form.
STATEMENT OF ACCOUNT
for Secondary Transmissions by
Cable Systems (Long Form)
Return to:
Library of Congress
Copyright Office
Licensing Division
101 Independence Ave. SE
Washington, DC 20557-6400
(202) 707-8150
FOR COPYRIGHT OFFICE USE ONLY
DATE RECEIVED
General instructions are at the
end of this form [pages i–viii].
SA3
Long Form
AMOUNT
$
ALLOCATION NUMBER
For courier deliveries,
see page ii of the general
instructions.
A
ACCOUNTING PERIOD COVERED BY THIS STATEMENT: (Check one of the boxes and fill in the year date.)
B
INSTRUCTIONS:
Give the full legal name of the owner of the cable system in line 1. If the owner is a subsidiary of another corporation, give the full
corporate title of the subsidiary, not that of the parent corporation.
In line 2, list any other names under which the owner conducts the business of the cable system.
If there were different owners during the accounting period, only the owner on the last day of the accounting period should submit
a single statement of account and royalty fee payment covering the entire accounting period.
Accounting
Period
Owner
■ January 1–June 30 . . . . . . . . . . . . . . .
(Year)
■ July 1–December 31 . . . . . . . . . . . . . . .
(Year)
■ Check here if this is the system’s first filing. If not, enter the system’s ID number assigned by the Licensing Division. __________
1
LEGAL NAME OF OWNER OF CABLE SYSTEM:
2
BUSINESS NAME(S) OF OWNER OF CABLE SYSTEM (IF DIFFERENT):
3
MAILING ADDRESS OF OWNER OF CABLE SYSTEM:
...............................................................................................................
(Number, street, rural route, apartment, or suite number)
...............................................................................................................
(City, town, state, zip)
INSTRUCTIONS: In line 1, give any business or trade names used to identify the business and operation of the system unless these
names already appear in space B. In line 2, give the mailing address of the system, if different from the address given in space B.
C
System
1
IDENTIFICATION OF CABLE SYSTEM:
MAILING ADDRESS OF CABLE SYSTEM:
2
...............................................................................................................
(Number, street, rural route, apartment, or suite number)
...............................................................................................................
(City, town, state, zip code)
D
6
Area
Served
First
Community
Instructions: For complete space D instructions, see page 1b. Identify only the first community served below and relist on page 1b with
all communities.
CITY OR TOWN
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Below is a sample for reporting communities if you report multiple channel line-ups in Space G.
6
CITY OR TOWN (SAMPLE)
Sample
STATE
STATE
CH LINE UP
SUB GRP#
. Alda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MD . . . . . . . . . . . A . . . . . . . . . . . . . .1. . . . . . . . .
.....
....
..
Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MD . . . . . . . . . . . B . . . . . . . . . . . . . .2. . . . . . . . .
.........
....
..
. Gering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MD . . . . . . . . . . . B . . . . . . . . . . . . . .3. . . . . . . . .
.......
....
..
Privacy Act Notice: Section 111 of title 17 of the United States Code authorizes the Copyright Office to collect the personally identifying information (PII) requested on this
form in order to process your statement of account. PII is any personal information that can be used to identify or trace an individual, such as name, address and telephone
numbers. By providing PII, you are agreeing to the routine use of it to establish and maintain a public record, which includes appearing in the Office's public indexes and in
search reports prepared for the public. The effects of not providing the PII requested is that it may delay processing of your statement of account and its placement in the
completed record of statements of account, and it may affect the legal sufficiency of the filing, a determination that would be made by a court of law.
Form SA3c Rev: 12 ⁄ 2010
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FORM SA3. PAGE 1b.
LEGAL NAME OF OWNER OF CABLE SYSTEM:
Name
Instructions: List each separate community served by the cable system. A “community” is the same as a “community unit” as defined
in FCC rules: “a separate and distinct community or municipal entity (including unincorporated communities within unincorporated
D
areas and including single, discrete unincorporated areas.” 47 C.F.R. §76.5(dd). The first community that you list will serve as a form
of system identification hereafter known as the “first community.” Please use it as the first community on all future filings.
Note: Entities and properties such as hotels, apartments, condominiums, or mobile home parks should be reported in parentheses below
the identified city or town.
Area
Served
all communities receive the same complement of television broadcast stations (i.e., one channel line-up for all), then either associate
If
all communities with the channel line-up “A” in the appropriate column below or leave the column blank. If you report any stations
on a partially distant or partially permitted basis in the DSE Schedule, associate each relevant community with a subscriber group,
designated by a number (based on your reporting from Part 9).
When reporting the carriage of television broadcast stations on a community-by-community basis, associate each community with a
channel line-up designated by an alpha-letter(s) (based on your Space G reporting) and a subscriber group designated by a number
(based on your reporting from Part 9 of the DSE Schedule) in the appropriate columns below.
CITY OR TOWN
STATE
CH LINE UP
SUB GRP#
First
Community
▼
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FORM SA3. PAGE 2.
LEGAL NAME OF OWNER OF CABLE SYSTEM:
Name
E
Secondary
Transmission
Service: Subscribers and
Rates
SECONDARY TRANSMISSION SERVICE: SUBSCRIBERS AND RATES
In General: The information in space E should cover all categories of secondary transmission service of the cable
system, that is, the retransmission of television and radio broadcasts by your system to subscribers. Give information
about other services (including pay cable) in space F, not here. All the facts you state must be those existing on the
last day of the accounting period (June 30 or December 31, as the case may be).
Number of Subscribers: Both blocks in space E call for the number of subscribers to the cable system, broken
down by categories of secondary transmission service. In general, you can compute the number of subscribers in
each category by counting the number of billings in that category (the number of persons or organizations charged
separately for the particular service at the rate indicated—not the number of sets receiving service).
Rate: Give the standard rate charged for each category of service. Include both the amount of the charge and the
unit in which it is generally billed. (Example: “$8/mth”). Summarize any standard rate variations within a particular rate
category, but do not include discounts allowed for advance payment.
Block 1: In the left-hand block in space E, the form lists the categories of secondary transmission service that cable
systems most commonly provide to their subscribers. Give the number of subscribers and rate for each listed category
that applies to your system. Note: Where an individual or organization is receiving service that falls under different
categories, that person or entity should be counted as a subscriber in each applicable category. Example: a residential
subscriber who pays extra for cable service to additional sets would be included in the count under “Service to the
first set” and would be counted once again under “Service to additional set(s).”
Block 2: If your cable system has rate categories for secondary transmission service that are different from those
printed in block 1 (for example, tiers of services that include one or more secondary transmissions), list them, together
with the number of subscribers and rates, in the right-hand block. A two- or three-word description of the service is
sufficient.
BLOCK 2
BLOCK 1
CATEGORY OF SERVICE
Residential:
• Service to first set
• Service to additional set(s)
• FM radio (if separate rate)
Motel, hotel
Commercial
Converter
• Residential
• Non-residential
F
Services
Other Than
Secondary
Transmissions:
Rates
NO. OF
SUBSCRIBERS
RATE
CATEGORY OF SERVICE
NO. OF
SUBSCRIBERS
RATE
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SERVICES OTHER THAN SECONDARY TRANSMISSIONS: RATES
In General: Space F calls for rate (not subscriber) information with respect to all your cable system’s services that were
not covered in space E, that is, those services that are not offered in combination with any secondary transmission
service for a single fee. There are two exceptions: you do not need to give rate information concerning (1) services
furnished at cost or (2) services or facilities furnished to nonsubscribers. Rate information should include both the
amount of the charge and the unit in which it is usually billed. If any rates are charged on a variable per-program basis,
enter only the letters “PP” in the rate column.
Block 1: Give the standard rate charged by the cable system for each of the applicable services listed.
Block 2: List any services that your cable system furnished or offered during the accounting period that were not
listed in block 1 and for which a separate charge was made or established. List these other services in the form of a
brief (two- or three-word) description and include the rate for each.
BLOCK 1
CATEGORY OF SERVICE
Continuing Services:
• Pay cable
• Pay cable—add’l channel
• Fire protection
•Burglar protection
Installation: Residential
• First set
• Additional set(s)
• FM radio (if separate rate)
• Converter
RATE
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CATEGORY OF SERVICE
Installation: Non-residential
• Motel, hotel
• Commercial
• Pay cable
• Pay cable—add’l channel
• Fire protection
• Burglar protection
Other services:
• Reconnect
• Disconnect
• Outlet relocation
• Move to new address
BLOCK 2
RATE
CATEGORY OF SERVICE
RATE
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FORM SA3. PAGE 3.
LEGAL NAME OF OWNER OF CABLE SYSTEM:
Name
PRIMARY TRANSMITTERS: TELEVISION
In General: In space G, identify every television station (including translator stations and low power television stations)
carried by your cable system during the accounting period, except (1) stations carried only on a part-time basis under
FCC rules and regulations in effect on June 24, 1981, permitting the carriage of certain network programs [sections
76.59(d)(2) and (4), 76.61(e)(2) and (4), or 76.63 (referring to 76.61(e)(2) and (4))]; and (2) certain stations carried on a
substitute program basis, as explained in the next paragraph.
Substitute Basis Stations: With respect to any distant stations carried by your cable system on a substitute program
basis under specific FCC rules, regulations, or authorizations:
• Do not list the station here in space G—but do list it in space I (the Special Statement and Program Log)—if the
station was carried only on a substitute basis.
• List the station here, and also in space I, if the station was carried both on a substitute basis and also on some other
basis. For further information concerning substitute basis stations, see page (v) of the general instructions.
Column 1: List each station’s call sign. Do not report origination program services such as HBO, ESPN, etc. Identify
each multicast stream associated with a station according to its over-the-air designation. For example, report multicast stream as “WETA-2” Simulcast streams must be reported in column 1 (list each stream separately; for example
.
WETA-simulcast).
Column 2: Give the channel number the FCC has assigned to the television station for broadcasting over-the-air in
its community of license. For example, WRC is Channel 4 in Washington, D.C. This may be different from the channel
on which your cable system carried the station.
Column 3: Indicate in each case whether the station is a network station, an independent station, or a noncommercial
educational station, by entering the letter “N” (for network), “N-M” (for network multicast), “I” (for independent), “I-M”
(for independent multicast), “E” (for noncommercial educational), or “E-M” (for noncommercial educational multicast).
For the meaning of these terms, see page (v) of the general instructions.
Column 4: If the station is outside the local service area, (i.e. “distant”), enter “Yes”. If not, enter “No”. For an explanation of local service area, see page (v) of the general instructions.
Column 5: If you have entered “Yes” in column 4, you must complete column 5, stating the basis on which your
cable system carried the distant station during the accounting period. Indicate by entering “LAC” if your cable system
carried the distant station on a part-time basis because of lack of activated channel capacity.
For the retransmission of a distant multicast stream that is not subject to a royalty payment because it is the subject
of a written agreement entered into on or before June 30, 2009, between a cable system or an association representing
the cable system and a primary transmitter or an association representing the primary transmitter, enter the designation “E” (exempt). For simulcasts, also enter “E”. If you carried the channel on any other basis, enter “O.” For a further
explanation of these three categories, see page (v) of the general instructions.
Column 6: Give the location of each station. For U.S. stations, list the community to which the station is licensed by the
FCC. For Mexican or Canadian stations, if any, give the name of the community with which the station is identified.
G
Primary
Transmitters:
Television
Note: If you are utilizing multiple channel line-ups, use a separate space G for each channel line-up.
1. CALL
SIGN
2. B’CAST
CHANNEL
NUMBER
3. TYPE
OF
STATION
4. DISTANT?
(Yes or No)
5. BASIS OF
CARRIAGE
(If Distant)
6. LOCATION OF STATION
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FORM SA3. PAGE 4.
LEGAL NAME OF OWNER OF CABLE SYSTEM:
Name
H
Primary
Transmitters:
Radio
PRIMARY TRANSMITTERS: RADIO
In General: List every radio station carried on a separate and discrete basis and list those FM stations carried on an
all-band basis whose signals were “generally receivable” by your cable system during the accounting period.
Special Instructions Concerning All-Band FM Carriage: Under Copyright Office regulations, an FM signal is generally
receivable if (1) it is carried by the system whenever it is received at the system’s headend, and (2) it can be expected,
on the basis of monitoring, to be received at the headend, with the system’s FM antenna, during certain stated intervals.
For detailed information about the the Copyright Office regulations on this point, see page (v) of the general instructions.
Column 1: Identify the call sign of each station carried.
Column 2: State whether the station is AM or FM.
Column 3: If the radio station’s signal was electronically processed by the cable system as a separate and discrete
signal, indicate this by placing a check mark in the “S/D” column.
Column 4: Give the station’s location (the community to which the station is licensed by the FCC or, in the case of
Mexican or Canadian stations, if any, the community with which the station is identified).
CALL SIGN
AM or FM S/D LOCATION OF STATION
CALL SIGN AM or FM S/D LOCATION OF STATION
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FORM SA3. PAGE 5.
LEGAL NAME OF OWNER OF CABLE SYSTEM:
Name
SUBSTITUTE CARRIAGE: SPECIAL STATEMENT AND PROGRAM LOG
In General: In space I, identify every nonnetwork television program broadcast by a distant station that your cable system
carried on a substitute basis during the accounting period, under specific present and former FCC rules, regulations, or
authorizations. For a further explanation of the programming that must be included in this log, see page (v) of the general
instructions.
1. SPECIAL STATEMENT CONCERNING SUBSTITUTE CARRIAGE
• During the accounting period, did your cable system carry, on a substitute basis, any nonnetwork television program
c Yes c No
broadcast by a distant station?
Note: If your answer is “No”, leave the rest of this page blank. If your answer is “Yes,” you must complete the program
log in block 2.
I
Substitute
Carriage:
Special
Statement and
Program Log
2. LOG OF SUBSTITUTE PROGRAMS
In General: List each substitute program on a separate line. Use abbreviations wherever possible, if their meaning is
clear. If you need more space, please attach additional pages.
Column 1: Give the title of every nonnetwork television program (substitute program) that, during the accounting
period, was broadcast by a distant station and that your cable system substituted for the programming of another station
under certain FCC rules, regulations, or authorizations. See page (v) of the general instructions for further information.
Do not use general categories like “movies” or “basketball.” List specific program titles, for example, “I Love Lucy” or
“NBA Basketball: 76ers vs. Bulls.”
Column 2: If the program was broadcast live, enter “Yes.” Otherwise enter “No.”
Column 3: Give the call sign of the station broadcasting the substitute program.
Column 4: Give the broadcast station’s location (the community to which the station is licensed by the FCC or, in
the case of Mexican or Canadian stations, if any, the community with which the station is identified).
Column 5: Give the month and day when your system carried the substitute program. Use numerals, with the month
first. Example: for May 7 give “5/7.”
Column 6: State the times when the substitute program was carried by your cable system. List the times accurately
to the nearest five minutes. Example: a program carried by a system from 6:01:15 p.m. to 6:28:30 p.m. should be
stated as “6:00–6:30 p.m.”
Column 7: Enter the letter “R” if the listed program was substituted for programming that your system was required
to delete under FCC rules and regulations in effect during the accounting period; enter the letter “P” if the listed program was substituted for programming that your system was permitted to delete under FCC rules and regulations in
effect on October 19, 1976.
WHEN SUBSTITUTE
CARRIAGE OCCURRED
SUBSTITUTE PROGRAM
1. TITLE OF PROGRAM
2. LIVE?
Yes or No
3. STATION’S
CALL SIGN
4. STATION’S LOCATION
5. MONTH
AND DAY
6. TIMES
FROM — TO
7. REASON
FOR
DELETION
—
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FORM SA3. PAGE 6.
LEGAL NAME OF OWNER OF CABLE SYSTEM:
Name
J
Part-Time
Carriage
Log
PART-TIME CARRIAGE LOG
In General: This space ties in with column 5 of space G. If you listed a station’s basis of carriage as “LAC” for parttime carriage due to lack of activated channel capacity, you are required to complete this log giving the total dates and
hours your system carried that station. If you need more space, please attach additional pages.
Column 1 (Call sign): Give the call sign of every distant station whose basis of carriage you identified by “LAC” in
column 5 of space G.
Column 2 (Dates and hours of carriage): For each station, list the dates and hours when part-time carriage occurred during the accounting period.
• Give the month and day when the carriage occurred. Use numerals, with the month first. Example: for April 10 give
“4/10.”
• State the starting and ending times of carriage to the nearest quarter hour. In any case where carriage ran to the end
of the television station’s broadcast day, you may give an approximate ending hour, followed by the abbreviation
“app.” Example: “12:30 a.m.– 3:15 a.m. app.”
• You may group together any dates when the hours of carriage were the same. Example: “5/10-5/14, 6:00 p.m.–
12:00 p.m.”
DATES AND HOURS OF PART-TIME CARRIAGE
WHEN CARRIAGE OCCURRED
CALL SIGN
DATE
FROM
HOURS
WHEN CARRIAGE OCCURRED
CALL SIGN
TO
DATE
FROM
HOURS
TO
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FORM SA3. PAGE 7.
LEGAL NAME OF OWNER OF CABLE SYSTEM:
Name
GROSS RECEIPTS
Instructions: The figure you give in this space determines the form you file and the amount you pay. Enter the total of
K
Gross Receipts
6
all amounts (gross receipts) paid to your cable system by subscribers for the system’s secondary transmission service
(as identified in space E) during the accounting period. For a further explanation of how to compute this amount, see
page (vii) of the general instructions.
Gross receipts from subscribers for secondary transmission service(s)
during the accounting period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$. . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Amount of gross receipts)
IMPORTANT: You must complete a statement in space P concerning gross receipts.
COPYRIGHT ROYALTY FEE
▼
▼
L
Copyright
Royalty Fee
If part 8 or part 9, block A, of the DSE schedule was completed, the base rate fee should be entered on line 1 of
block 3 below.
If part 6 of the DSE schedule was completed, the amount from line 7 of block C should be entered on line 2 in block
3 below.
▼
Instructions: Use the blocks in this space L to determine the royalty fee you owe:
• Complete block 1, showing your minimum fee.
• Complete block 2, showing whether your system carried any distant television stations.
• If your system did not carry any distant television stations, leave block 3 blank. Enter the amount of the minimum
fee from block 1 on line 1 of block 4, and calculate the total royalty fee.
• If your system did carry any distant television stations, you must complete the applicable parts of the DSE Schedule
accompanying this form and attach the schedule to your statement of account.
If part 7 or part 9, block B, of the DSE schedule was completed, the surcharge amount should be entered on line
2 in block 4 below.
Block
MINIMUM FEE: All cable systems with semiannual gross receipts of $527,600 or more are required to pay at
least the minimum fee, regardless of whether they carried any distant stations. This fee is 1.064 percent of the
system’s gross receipts for the accounting period.
Line 1. Enter the amount of gross receipts from space K . . . . . . . .
Line 2. Multiply the amount in line 1 by 0.01064
Enter the result here.
$
This is your minimum fee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
▼
▼
1
2
Block
Line 1. BASE RATE FEE: Enter the base rate fee from either part 8, section 3 or
4, or part 9, block A of the DSE schedule. If none, enter zero . . . . . . . . . . . . . . $ .........................................
Line 2. 3.75 Fee: Enter the total fee from line 7, block C, part 6 of the DSE
schedule. If none, enter zero . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..........................................
▼
3
DISTANT TELEVISION STATIONS CARRIED: Your answer here must agree with the information you gave in
space G. If, in space G, you identified any stations as “distant” by stating “Yes” in column 4, you must check
“Yes” in this block.
• Did your cable system carry any distant television stations during the accounting period?
c Yes—Complete the DSE schedule.
c No—Leave block 3 below blank and complete line 1, block 4.
▼
Block
Line 1. BASE RATE FEE/3.75 FEE or MINIMUM FEE: Enter either the minimum fee
from block 1 or the sum of the base rate fee / 3.75 fee from block 3, line 3,
whichever is larger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
▼
Line 2. SYNDICATED EXCLUSIVITY SURCHARGE: Enter the fee from either part 7
(block D, section 3 or 4) or part 9 (block B) of the DSE schedule. If none, enter
zero. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Line 3. INTEREST CHARGE: Enter the amount from line 4, space Q, page 9 (Interest
Worksheet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
▼
4
$
.
TOTAL ROYALTY FEE. Add Lines 1, 2 and 3 of block 4 and enter total here . . . . .$ . . . . . . . . . . . . . . . . . . . . . . . . . . . .
▼
Block
▼
▼
Line 3. Add lines 1 and 2 and enter
here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ..........................................
Remit this amount via electronic payment payable to Register of Copyrights. (See page (i) of the
general instructions for more information.)
Cable systems
submitting
additional
deposits under
Section 111(d)(7)
should contact
the Licensing
Division for the
appropriate
form for
submitting the
additional fees.
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FORM SA3. PAGE 8.
LEGAL NAME OF OWNER OF CABLE SYSTEM:
Name
M
Channels
Name
CHANNELS
Instructions: You must give (1) the number of channels on which the cable system carried television broadcast stations
to its subscribers and (2) the cable system’s total number of activated channels, during the accounting period.
1. Enter the total number of channels on which the cable
system carried television broadcast stations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Enter the total number of activated channels
on which the cable system carried television broadcast stations
and nonbroadcast services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
N
Individual to
Be Contacted
for Further
Information
INDIVIDUAL TO BE CONTACTED IF FURTHER INFORMATION IS NEEDED: (Identify an individual to whom
we can write or call about this statement of account.)
Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Telephone . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Area code)
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Number, street, rural route, apartment, or suite number)
....................................................................................................................
(City, town, state, zip)
Email (optional) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fax (optional) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
O
Certification
CERTIFICATION (This statement of account must be certified and signed in accordance with Copyright Office regulations, as explained in the general instructions.)
• I, the undersigned, hereby certify that (Check one, but only one, of the boxes.)
c
(Owner other than corporation or partnership) I am the owner of the cable system as identified in line 1
of space B; or
c
(Agent of owner other than corporation or partnership) I am the duly authorized agent of the owner of
the cable system as identified in line 1 of space B and that the owner is not a corporation or partnership; or
c
(Officer or partner) I am an officer (if a corporation) or a partner (if a partnership) of the legal entity identified as
owner of the cable system in line 1 of space B.
• I have examined the statement of account and hereby declare under penalty of law that all statements of fact
contained herein are true, complete, and correct to the best of my knowledge, information, and belief, and are
made in good faith. [18 U.S.C., Section 1001(1986)]
☛
Handwritten signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Typed or printed name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Title: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Title of official position held in corporation or partnership)
Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Privacy Act Notice: Section 111 of title 17 of the United States Code authorizes the Copyright Office to collect the personally identifying information (PII) requested on this
form in order to process your statement of account. PII is any personal information that can be used to identify or trace an individual, such as name, address and telephone
numbers. By providing PII, you are agreeing to the routine use of it to establish and maintain a public record, which includes appearing in the Office's public indexes and in
search reports prepared for the public. The effects of not providing the PII requested is that it may delay processing of your statement of account and its placement in the
completed record of statements of account, and it may affect the legal sufficiency of the filing, a determination that would be made by a court of law.
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FORM SA3. PAGE 9.
LEGAL NAME OF OWNER OF CABLE SYSTEM:
Name
SPECIAL STATEMENT CONCERNING GROSS RECEIPTS EXCLUSIONS
The Satellite Home Viewer Act of 1988 amended Title 17, section 111(d)(1)(A), of the Copyright Act by adding the following sentence:
“In determining the total number of subscribers and the gross amounts paid to the cable system for the basic
service of providing secondary transmissions of primary broadcast transmitters, the system shall not include sub scribers and amounts collected from subscribers receiving secondary transmissions pursuant to section 119.”
P
Special
Statement
Concerning
Gross Receipts
Exclusions
For more information on when to exclude these amounts, see the note on page (vii) of the general instructions.
During the accounting period did the cable system exclude any amounts of gross receipts for secondary transmissions
made by satellite carriers to satellite dish owners?
c
NO
c
YES. Enter the total here and list the satellite carrier(s) below. . . . . . . . . . . . . . . . . . . . . $
......................................................
...............................................
...........................................................
.....................................................
..............................................
.........................................................
Name
Name
Mailing address
Mailing address
...........................................................
.........................................................
INTEREST ASSESSMENT
You must complete this worksheet for those royalty payments submitted as a result of a late payment or underpayment.
For an explanation of interest assessment, see page (viii) of the general instructions.
Line 1
Enter the amount of late payment or underpayment . . . . . . . . . . . . . . . . . . . . . . . .
$
x
Line 3
Line 4
Interest
Assessment
%
x
Line 2
Q
days
Multiply line 1 by the interest rate* and enter the sum here . . . . . . . . . . . . . . . . . .
Multiply line 2 by the number of days late and enter the sum here . . . . . . . . . . .
Multiply line 3 by 0.00274** enter here and on line 3, block 4,
space L, (page 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
x 0.00274
(interest charge)
* To view the interest rate chart click on www.copyright.gov/licensing/interest-rate.pdf. For further assistance please
contact the Licensing Division at (202) 707-8150 or licensing@loc.gov.
** This is the decimal equivalent of 1/365, which is the interest assessment for one day late.
NOTE: If you are filing this worksheet covering a statement of account already submitted to the Copyright Office,
please list below the owner, address, first community served, accounting period, and ID number as given in the original
filing.
Owner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
First community served . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accounting period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ID number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Privacy Act Notice: Section 111 of title 17 of the United States Code authorizes the Copyright Office to collect the personally identifying information (PII) requested on this
form in order to process your statement of account. PII is any personal information that can be used to identify or trace an individual, such as name, address and telephone
numbers. By providing PII, you are agreeing to the routine use of it to establish and maintain a public record, which includes appearing in the Office's public indexes and in
search reports prepared for the public. The effects of not providing the PII requested is that it may delay processing of your statement of account and its placement in the
completed record of statements of account, and it may affect the legal sufficiency of the filing, a determination that would be made by a court of law.
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DSE SCHEDULE. PAGE 10.
INSTRUCTIONS FOR DSE SCHEDULE
WHAT IS A “DSE”
The term “distant signal equivalent” (DSE) generally refers to the numerical
value given by the Copyright Act to each distant television station carried
by a cable system during an accounting period. Your system’s total number
of DSEs determines the royalty you owe. For the full definition, see page
(v) of the General Instructions.
FORMULAS FOR COMPUTING A STATION’S DSE
There are two different formulas for computing DSEs: (1) a basic formula
for all distant stations listed in space G (page 3), and (2) a special formula for those stations carried on a substitute basis and listed in space
I (page 5). (Note that if a particular station is listed in both space G and
space I, a DSE must be computed twice for that station: once under the
basic formula and again under the special formula. However, a station’s
total DSE is not to exceed its full type-value. If this happens, contact the
Licensing Division.)
BASIC FORMULA: FOR ALL DISTANT STATIONS LISTED
IN SPACE G OF SA3 (LONG FORM)
Step 1: Determine the station’s type-value. For purposes of computing
DSEs, the Copyright Act gives different values to distant stations depending upon their type. If, as shown in space G of your statement of account
(page 3), a distant station is:
• Independent: its type-value is. .......................................................1.00
.
• Network: its type-value is. ..............................................................0.25
.
• Noncommercial educational: its type-value is..............................0.25
Note that local stations are not counted at all in computing DSEs.
Step 2: Calculate the station’s basis of carriage value: The DSE of
a station also depends on its basis of carriage. If, as shown in space G
of your Form SA3, the station was carried part time because of lack of
activated channel capacity, its basis of carriage value is determined by (1)
calculating the number of hours the cable system carried the station during
the accounting period, and (2) dividing that number by the total number of
hours the station broadcast over the air during the accounting period. The
basis of carriage value for all other stations listed in space G is 1.0.
Step 3: Multiply the result of step 1 by the result of step 2. This gives
you the particular station’s DSE for the accounting period. (Note that for
stations other than those carried on a part-time basis due to lack of activated channel capacity, actual multiplication is not necessary since the
DSE
