Formal Complaint Intake Form {485}

FCC 485 June 2019 Federal Communications Commission Washington, D.C. 20554 OMB Control Number 3060-0411 COMPLAINT INTAKE FORM FOR COMPLAINTS FILED UNDER SECTIONS 208, 224, 255, 716, AND 717 OF THE COMMUNICATIONS ACT OF 1934, AS AMENDED 1. Case Name: 2. Complainant's Name, Address, Phone and Facsimile Number, e-mail address (if applicable): 3. Defendant's Name, Address, Phone and Facsimile Number (to the extent known), e - mail address (if applicable): 4. Complaint alleges violation of the following provisions of the Communications Act of 1934, as amended: Answer Yes, No, or N/A to the following: 5. Complaint conforms to the specifications prescribed by 47 CFR 247 1 .721. 6. If Complaint concerns pole attachments, Complaint also conforms to the specifications prescribed by 47 CFR 247 1.1404. 7. Complaint conforms to the format and content requirements of the Commission222s rules, including but not limited to: a. If damages are sought, the Complaint comports with the specifications prescribed by 47 CFR 247 1.723. b. Complaint contains a certification that complies with 47 CFR 247 1.722(g). c. Complaint contains a certification that complies with 47 CFR 247 1.722(h). d. Complaint includes an information designation that complies with 47 CFR 247 1.722(i). e. Complaint attaches copies of all affidavits, tariff provisions, written agreements, offers, counter-offers, denials, correspondence, documents, data compilations, and tangible things in the complainant's possession, custody, or control, upon which the complainant relies or intends to rely to support the facts alleged and legal arguments made in the Complaint. f. Complaint attaches a certificate of service that conforms to the specifications prescribed by 47 CFR 247247 1.47(g) and 1.734(f). g. Complaint attaches verification of payment of filing fee in accordance with 47 CFR 247247 1.722(k) and 1.1106. 8. If Complaint is filed pursuant to 47 U.S.C. 247 271(d)(6)(B), complainant indicates whether it is willing to waive the 90-day complaint resolution deadline. 9. Complainant has service copy of Complaint by hand-delivery on either the named defendant or one of the defendant222s registered agents for service of process in accordance with 47 CFR 247247 l.47(e) and l.734(c). 10. If more than ten pages, the Complaint contains a table of contents and summary, as specified in 47 CFR 247 l.49(b) and (c). 11. Complainant has filed the correct number of copies required by 47 CFR 247 1.51(c), if applicable, and 47 CFR 247 l.734(b). 12. If Complaint is by multiple complainants, it complies with the requirements of 47 CFR 247 l .725(a). 13. If Complaint involves multiple grounds, it complies with the requirements of 47 CFR 247 1.725(b). 14. If Complaint is directed against multiple defendants, it complies with the requirements of 47 CFR 247 l .734. 15. Complaint conforms to the specifications prescribed by 47 CFR 2471.49. American LegalNet, Inc. www.FormsWorkFlow.com Instructions 1. This form must be completed by the Complainant. 2. Submit a completed intake form with any formal complaint to indicate that the complaint satisfies all procedural and substantive requirements of the Communications Act of 1934, as amended, and applicable FCC rules. 3. The original form must be filed with the original complaint and a copy of the form attached to each copy of the complaint that is either filed with the Commission or served on the opposing party. Notice: Sections 208, 224, 255, 716, and 717 of the Communications Act of 1934, as amended, provide the statutory framework for our current rules for resolving formal complaints. Pursuant to 47 CFR 247 l.722(j), a completed intake form must be submitted with any formal complaint to indicate that the complaint satisfies the applicable procedural and substantive requirements under the Communications Act of 1934, as amended, and the FCC's rules. The information will be used by the Commission to determine the sufficiency of the complaint and aid its processing by the staff. Remember: 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 Office of Management and Budget (OMB) control number. This collection has been assigned an OMB control number of 3060-0411. 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 relevant records, gather and maintain the required data, and actually complete and review the intake form. If you have any comments on this estimate, or how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, OMD-PERM, Washington, D.C. 20554, Paperwork Reduction Project (3060- 0411). We also will accept your comments via Internet if you send them to pra@fcc.gov Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. The foregoing Notice is required by the Privacy Act of 1974, P.L. 93-579, December 31, 1994, 5 U.S.C. 552a(e)(3), and the Paperwork Reduction Act of 1995, P.L. 104-13, 44 U.S.C. Section 3501. The Commission 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 that you provide to determine the sufficiency of the complaint and to assist in processing and resolving the complaint. If we believe there may be a violation or potential violation of a Federal or state statute or regulation, rule, or order issued by a Federal or state agency, your form may be referred to the appropriate 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 Form may be disclosed to the Department of Justice, court, or other adjudicative body when: (a) the Commission; or (b) any employee of the Commission; or (c) the United States government, is a party to a proceeding before the body or has an interest in the proceeding. If you owe a past due debt to the Federal government, the taxpayer identification number (such as your social security number) and other information you provide also may be disclosed to the Department of the Treasury Financial Management Service, other Federal agencies, and/or your employer to offset your salary, IRS tax refund, or other payments to collect that debt. The Commission also may provide this information to those agencies through the matching of computer records where authorized. FCC Form 485 226 Instructions June 2019 American LegalNet, Inc. www.FormsWorkFlow.com